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Buttaro: Primary Care, A Collaborative Practice, 5th Ed.

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Buttaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 1: The Evolving Landscape of Collaborative Practice Test Bank Multiple Choice 1. Which assessments of care providers are performed ... as part of the Value Based Purchasing initiative? Select all that apply. a. Appraising costs per case of care for Medicare patients b. Assessing patients’ satisfaction with hospital care c. Evaluating available evidence to guide clinical care guidelines d. Monitoring mortality rates of all patients with pneumonia e. Requiring advanced IT standards and minimum cash reserves ANS: A, B, D Value Based Purchasing looks at five domain areas of processes of care, including efficiency of care (cost per case), experience of care (patient satisfaction measures), and outcomes of care (mortality rates for certain conditions. Evaluation of evidence to guide clinical care is part of evidence-based practice. The requirements for IT standards and financial status are part of Accountable Care Organization standards. REF: Value Based Purchasing 2. What was an important finding of the Advisory Board survey of 2014 about primary care preferences of patients? a. Associations with area hospitals b. Costs of ambulatory care c. Ease of access to care d. The ratio of providers to patients ANS: C As part of the 2014 survey, the Advisory Board learned that patients desired 24/7 access to care, walk-in settings and the ability to be seen within 30 minutes, and care that is close to home. Associations with hospitals, costs of care, and the ratio of providers to patients were not part of these results. REF: The New Look of Primary Care 3. A small, rural hospital is part of an Accountable Care Organization (ACO) and is designated as a Level 1 ACO. What is part of this designation? a. Bonuses based on achievement of benchmarksTest Bank 2 b. Care coordination for chronic diseases c. Standards for minimum cash reserves d. Strict requirements for financial reporting ANS: A A Level 1 ACO has the least amount of financial risk and requirements, but receives shared savings bonuses based on achievement of benchmarks for quality measures and expenditures. Care coordination and minimum cash reserves standards are part of Level 2 ACO requirements. Level 3 ACOs have strict requirements for financial reporting. REF: Accountable Care OrganizationsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 2: Transitional Care Test Bank Multiple Choice 1. To reduce adverse events associated with care transitions, the Centers for Medicare and Medicaid Service have implemented which policy? a. Mandates for communication among primary caregivers and hospitalists b. Penalties for failure to perform medication reconciliations at time of discharge c. Reduction of payments for patients readmitted within 30 days after discharge d. Requirements for written discharge instructions for patients and caregivers ANS: C As a component of the Affordable Care Act, the Centers for Medicare and Medicaid Service developed the Readmissions Reduction Program reducing payments for certain patients readmitted within 30 days of discharge. The CMS did not mandate communication, institute penalties for failure to perform medication reconciliations, or require written discharge instructions. REF: Transitional Care 2. According to Naylor’s transitional care model, which intervention has resulted in lower costs and fewer rehospitalizations in high-risk older patients? a. Coordination of post-hospital care by advanced practice nurses b. Frequent post-hospital clinic visits with a primary care provider c. Inclusion of extended family members in the outpatient plan of care d. Telephone follow up by the pharmacist to assess medication compliance ANS: A Naylor’s transitional care model provided evidence that high risk older patients who had posthospital care coordinated by an APN had reduced rehospitalization rates. It did not include clinic visits with a primary care provider, inclusion of extended family members in the plan of care, or telephone follow up by a pharmacist. REF: Transitional Care 3. Which approaches are among those recommended by the Agency for Healthcare Research and Quality to improve health literacy in patients? Select all that apply. a. Empowering patients and families b. Giving written handouts for all teachingTest Bank 2 c. Highlighting no more than 7 key points d. Repeating the instructions e. Supplementing teaching with visual aids ANS: A, D, E AHRQ recommends using clear, simple language, highlighting 3 to 5 key points, using pictures or visual aids, repeating the instructions, using Teach Back, and empowering patients. Written communication is not part of the recommendations. REF: Health LiteracyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 3: Translating Research Into Clinical Practice Test Bank Multiple Choice 1. Which is the most appropriate research design for a Level III research study? a. Epidemiological studies b. Experimental design c. Qualitative studies d. Randomized clinical trials ANS: B The experimental design is the most appropriate design for a Level III study. Epidemiological studies are appropriate for Level II studies. Qualitative designs are useful for Level I studies. Randomized clinical trials are used for Level IV studies. REF: Level III Research/Experimental Design 2. What is the purpose of clinical research trials in the spectrum of translational research? a. Adoption of interventions and clinical practices into routine clinical care b. Determination of the basis of disease and various treatment options c. Examination of safety and effectiveness of various interventions d. Exploration of fundamental mechanisms of biology, disease, or behavior ANS: C Clinical research trials are concerned with determining the safety and effectiveness of interventions. Adoption of interventions and practices is part of clinical implementation. Determination of the basis of disease and treatment options is part of the pre-clinical research phase. Exploration of the fundamental mechanisms of biology, disease, or behavior is part of the basic research stage. REF: Translational Science Spectrum 3. What is the purpose of Level II research? a. To define characteristics of interest of groups of patients b. To demonstrate the effectiveness of an intervention or treatment c. To describe relationships among characteristics or variables d. To evaluate the nature of relationships between two variables ANS: CTest Bank 2 Level II research is concerned with describing the relationships among characteristics or variables. Level I research is conducted to define the characteristics of groups of patients. Level II research evaluates the nature of the relationships between variables. Level IV research is conducted to demonstrate the effectiveness of interventions or treatments. REF: Level II ResearchButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 4: The Patient, the Provider, and Primary Care: An Integrated Perspective Test Bank Multiple Choice 1. A patient takes glucosamine chondroitin to help control osteoarthritis pain. Which medications, taken in conjunction with this medication, are of concern? a. Anticholinergic drugs b. Beta blocker medications c. Blood-thinning agents d. Narcotic analgesics ANS: C Glucosamine chondroitin can prolong bleeding if taken with other blood-thinning agents. It does not have anticholinergic effects, cardiac effects or analgesic effects. REF: Alternative Therapies for Common Chronic Conditions/Joint Pain 2. The provider learns that a patient is taking herbal supplements for a variety of reasons. What is an important point to discuss with this patient about taking such supplements? a. Because they are not FDA approved, they are not safe b. Dietary supplements are safer than most prescription medications c. Many supplements lack clear clinical evidence of efficacy d. Supplements should not be taken with prescription medications ANS: C Many dietary supplements lack clinical evidence to support their use. Even though they are not FDA approved, federal law mandates that the products are safe and cannot make misleading claims about use. Supplements are not necessarily safer than prescription drugs. Supplements may be taken with prescription medications as long as the effects, side effects, and drug interactions are known. REF: Alternative Therapies for Common Chronic Conditions 3. Which dietary supplements have shown some effectiveness in reducing blood pressure in patients with hypertension? Select all that apply. a. Chromium picolinate b. Cinnamon c. CoQ10Test Bank 2 d. Garlic extract e. L-arginine ANS: C, D, E CoQ10, garlic extract, and L-arginine have demonstrated effectiveness in reducing blood pressure in some studies. Chromium picolinate and cinnamon have been studied for effects on glucose tolerance and fasting glucose. REF: Alternative Therapies for Common Chronic Conditions/Prehypertension and HypertensionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 5: Population-Based Care for Primary Care Providers Test Bank Multiple Choice 1. Which are key components of the Patient-Centered Medical Home? Select all that apply. a. Access to care b. Comprehensive care c. Coordination of care d. Provision of care by a single provider e. Storage of medical records ANS: A, B, C The Patient-Centered Medical Home is a team-based approach to providing care that is accessible, comprehensive, coordinated, longitudinal and high quality. It is not provided by a single provider, but is managed as a team. The original concept had to do with where medical records are stored, but this is not the working definition today. REF: The Patient-Centered Medical Home 2. The chronic care model (CCM) was developed to manage patients with complicated chronic conditions because the traditional acute care model a. could not provide efficient and cost-effective chronic care. b. did not meet longitudinal health careneeds for this population. c. did not offer ambulatory care services for these patients. d. put patients and families at the center of care. ANS: B The chronic care model was developed based on the recognition that the traditional acute care model did not meet longitudinal health care needs of patients with chronic and complicated conditions, not because of inefficiencies or costs. The traditional model does include ambulatory care, but that is not the focus. The traditional model does not typically place patients at the center of care. REF: Chronic Care Model 3. What are functions of patient registries in the chronic care model? Select all that apply. a. Alerting providers to medication interactionsTest Bank 2 b. Identifying appropriate specialists for referral c. Recommending routine screenings d. Reminding providers about immunizations e. Transmitting clinical dataabout patients ANS: A, C, D, E Patient registries are used to help manage patients at risk and include alerting providers about medication interactions, recommending routine screenings, reminders for immunizations, and transmitting clinical data. They are not used to identify or recommend providers or specialists. REF: Chronic Care Model/Clinical Information SystemsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 6: Health Literacy, Health Care Disparities, and Culturally Responsive Primary Care Test Bank Multiple Choice 1. A primary care provider administers the ―Newest Vital Sign‖ health literacy test to a patient newly diagnosed with a chronic disease. What information is gained by administering this test? a. Ability to calculate data, along with general knowledge about health b. Ease of using technology and understanding of graphic data c. Reading comprehension and reception of oral communication d. Understanding of and ability to discuss health care concerns ANS: A The ―Newest Vital Sign‖ tests asks patients to look at information on an ice cream container label and answer questions that evaluate ability to calculate caloric data and to grasp general knowledge about food allergies. It does not test understanding of technology or directly measure reading comprehension. It does not assess oral communication. The ―Ask Me 3‖ tool teaches patients to ask three primary questions about their health care and management. REF: Health Literacy Assessment 2. A female patient who is from the Middle East schedules an appointment in a primary care office. To provide culturally responsive care, what will the clinic personnel do when meeting this patient for the first time? a. Ensure that she is seen by a female provider b. Include a male family member in discussions about health care c. Inquire about the patient’s beliefs about health and treatment d. Research middle eastern cultural beliefs about health care ANS: C It is important not to make assumptions about beliefs and practices associated with health care and to ask the patient about these. While certain practices are common in some cultural and ethnic groups, assuming that all members of those groups follow those norms is not culturally responsive. REF: Address Cultural Variations Among Diverse Patient Groups 3. What is the main reason for using the REALM-SF instrument to evaluate health literacy? a. It assesses numeracy skills.Test Bank 2 b. It enhances patient-provider communication. c. It evaluates medical word recognition. d. It measures technology knowledge. ANS: C The REALM-SF is an easy and fast tool that measures medical word recognition. It does not evaluate numeracy. The ―Ask Me 3‖ tool enhances patient-provider communication. This tool does not evaluate understanding of technology. REF: Health Literacy AssessmentButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 7: Genetic Considerations in Primary Care Test Bank Multiple Choice 1. A patient expresses concern that she is at risk for breast cancer. To best assess the risk for this patient, what is the best initial action? a. Ask if there is a family history of breast cancer b. Gather and record a three-generation pedigree c. Ordera genetic test for the breast cancer gene d. Recommend direct-to-consumer genetic testing ANS: B The three-generation pedigree is the best way to evaluate genetic risk. Asking about a family history is not a systematic risk assessment and doesn’t specify who in the family has the history or whether there is a pattern. Genetic testing and DTC genetic testing are not the initial actions when assessing genetic risk. REF: Gathering a Family History 2. A patient asks about direct-to-consumer (DTC) genetic testing. What will the provider tell the patient? a. It is not useful for identifying genetic diseases. b. Much of the information does not predict disease risk. c. The results are shared with the patient’s insurance company. d. The results must be interpreted by a provider. ANS: B DTC testing gives a lot of information, but much of it does not contribute to disease prediction, since mutations are not necessarily related to specific diseases. The tests are useful, but must be interpreted accurately. The results are confidential and do not have to be interpreted by a provider. REF: Direct-to-Consumer (DTC) Genetic TestingButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 8: Risk Management Test Bank Multiple Choice 1. What are some causes for failures or delays in diagnosing patients resulting in malpractice claims? Select all that apply. a. Failing to recognize a medication complication b. Failing to request appropriate consultations c. Improper performance of a treatment d. Notacting on diagnostic test results e. Ordering a wrong medication ANS: B, D Failing to obtain consultations when indicated or not acting on diagnostic test results can lead to diagnosis-related failures. Failing to recognize medication complications and ordering a wrong medication lead to medication prescribing allegations. Improper performance of a treatment can lead to treatment related malpractice claims. REF: Nurse Practitioner Malpractice Claims 2. What is an important part of patient care that can minimize the risk of a formal patient complaint even when a mistake is made? a. Ensuring informed consent for all procedures b. Maintaining effective patient communication c. Monitoring patient compliance and adherence d. Providing complete documentation of visits ANS: B Effective patient communication is key to building trust and rapport and ineffective communication is a predictor for malpractice claims. The other items are important aspects of care and may help the provider during the investigation of a claim, but do not minimize the risk. REF: Communication IssuesButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 9: Adolescent Issues Test Bank Multiple Choice 1. Which behavior is most characteristic of early adolescence? a. Arguing with parents and teachers b. Assimilating adult roles and thinking c. Exhibiting fatigue more frequently d. Experimenting with sex and risky behaviors ANS: A Early adolescents challenge authority, experience wide mood swings, reject the ideation of childhood, and can be argumentative and disobedient. Middle adolescents experience fatigue and begin experimenting with sex and risky behaviors. Late adolescents begin to assimilate adult roles. REF: Introduction 2. What is the initial sign of puberty in the adolescent male? a. Deepening of the voice b. Elongation of the penis c. Nocturnal emissions d. Testicular enlargement ANS: D Testicular enlargement is the initial sign of puberty in adolescent males. Penile growth and nocturnal emissions occur later as does deepening of the voice. REF: Physical Development 3. A parent reports that an adolescent child does well in school but seems to consistently make poor decisions about activities with friends. What will the practitioner recommend as an approach to help the adolescent make better decisions? a. Correcting the adolescent’s decisions and judgments b. Listening without making suggestions about choices c. Making decisions for the adolescent to provide guidance d. Providing factual information about appropriate behavior ANS: BTest Bank 2 Listening without correcting is the best approach to help adolescents learn to make good decisions. Correcting the decisions, making decisions for the adolescent, or giving information that is unsolicited are not recommended. REF: Cognitive DevelopmentButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 10: LGBTQ Patient Care Test Bank Multiple Choice 1. Which is the most important factor limiting access to health care for sexual and gender minorities? a. Lack of familial support for SGM members b. Laws prohibiting full marriage equality c. Risky coping behaviors among SGM members d. Social stigma about being in this population ANS: B Since most people get health insurance through their employer or their spouse s employer, states which do not allow full marriage equality limit access to health care for LGBTQ people. The other causes are important, but this is the leading cause. REF: Introduction 2. What is the medical diagnostic term used to identify transgender patients? a. Gender dysphoria b. Gender expression disorder c. Gender identity disorder d. Gender role unconformity ANS: A Gender dysphoria is the term used to identify transgender patients in order to justify the medical necessity of treatments for transgender patients. It replaces the previous ―gender identity disorder‖ designation. REF: Access to CareButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 11: Pregnancy and Prenatal Care Test Bank Multiple Choice 1. A woman who is currently pregnant reports that she has had three previous pregnancies: twins delivered at 35 weeks gestation (both living), one at 38 weeks gestation (living), and one miscarriage at 16 weeks gestation. How will this be recorded as her G/TPAL in her electronic medical record? a. G4P:1113 b. G4P:1213 c. G5P:1113 d. G5P:1213 ANS: A Using the notation G (number of pregnancies), T (term deliveries), P (preterm deliveries), A (abortions – elective or spontaneous), L (living children), this patient is G4P:1113. She is in her fourth pregnancy, so is G4. She has had one delivery at 38 weeks or more, one delivery (of twins) at less than 36 weeks gestation, one spontaneous abortion, and has three living children. REF: Gravidity and Parity 2. A pregnant woman reports not having had any vaccinations as a child but requests vaccines during her pregnancy. Which vaccines may be given? Select all that apply. a. HPV b. Inactivated influenza c. Live, attenuated influenza d. MMR e. Tdap f. Varicella ANS: A, B, E Tdap is recommended to pregnant woman, optimally between 27 and 36 weeks gestation. Inactivated is strongly recommended and may be given at any point in the pregnancy. Hepatitis B is given to women at risk if needed. Live, attenuated influenza vaccine, MMR, and varicella vaccines are not recommended during pregnancy. REF: Health HistoryTest Bank 2 3. A pregnant woman who is overweight has no previous history of hypertension or diabetes. Her initial screening exam reveals a blood pressure of 140/90 and a fasting blood glucose of 128 mg/dL. What will the practitioner do? a. Initiate insulin therapy b. Monitor blood pressure and fasting blood glucose closely c. Prescribe an antihypertensive medication d. Refer the patient to a high-risk pregnancy specialist ANS: B This woman, although she has no previous history of HTN or DM, is at elevated risk because of obesity. Her initial screening lab values are at the high end of normal, indicating potential development of gestational HTN and gestational DM. The initial response of the practitioner should be to monitor the patient closely and consider treatment at the first signs of development of these complications. Referral is warranted when these conditions become severe. REF: Hypertension/DiabetesButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 12:Lactation Guidance Test Bank Multiple Choice 1. An infant who has just begun nursing develops hyperbilirubinemia. What will the provider tell the mother? a. To decrease the frequency of breastfeeding b. To supplement feedings with extra water c. To switch to formula until the bilirubin level drops d. To use a breast pump to increase her milk supply ANS: D Infants with suboptimal breastfeeding can have starvation jaundice and mothers should be encouraged to increase the frequency of breastfeeding and should be offered a breast pump to increase milk supply. It is not recommended to supplement with water or sugar water or to switch to formula. REF: Physiologic Jaundice 2. The mother of a 3-day-old newborn reports that her infant nurses every 4 hours during the day and sleeps 6 hours at night. What will the provider recommend? a. Awakening the baby every 3 hours to nurse b. Continuing this schedule until the infant is 6 months old c. Ensuring that her infant nurses for 15 to 20 minutes each time d. Pumping her breasts to maintain her milk supply ANS: A Newborn infants should nurse 8 to 12 times daily and mothers should be encouraged to awaken a sleepy baby to nurse every 3 hours or more often. The feedings will gradually space out as the infant is older. REF: The First Few Days 3. A mother who has been breastfeeding her infant for several weeks develops a fever, breast warmth, and breast tenderness. What will the provider recommend? a. Ice packs and decreased frequency of nursing b. Ice packsand increased frequency of nursing c. Warm packs and decreased frequency of nursing d. Warm packsand increased frequency of nursingTest Bank 2 ANS: D This mother has symptoms of mastitis. She should be encouraged to use warm packs for comfort and to increase the frequency of nursing to relieve the pressure. REF: MastitisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 13: Aging and Common Geriatric Syndromes Test Bank Multiple Choice 1. When prescribing medications to an 80-year-old patient, the provider will a. begin with higher doses and decrease according to the patient’s response. b. consult the Beers list to help identify potentially problematic drugs. c. ensure that the patient does not take more than five concurrent medications. d. review all patient medications at the annual health maintenance visit. ANS: B The Beers list provides a list of potentially inappropriate medications in all patients age 65 and older and helps minimize drug-related problems in this age group. Older patients should be started on lower doses with gradual increase of doses depending on response and side effects. Patients who take five or more drugs are at increased risk for problems of polypharmacy, but many will need to take more than five drugs; providers must monitor their response more closely. Medications should be reviewed at all visits, not just annually. REF: Polypharmacy/Consequences of Polypharmacy/Management 2. An 80-year-old woman who lives alone is noted to have a recent weight loss of 5 pounds. She appears somewhat confused, according to her daughter, who is concerned that she is developing dementia. The provider learns that the woman still drives, volunteers at the local hospital, and attends a book club with several friends once a month. What is the initial step in evaluating this patient? a. Obtain a CBC, serum electrolytes, BUN, and glucose b. Ordering a CBC, serum ferritin, and TIBC c. Referring the patient to a dietician for nutritional evaluation d. Referring the patient to a neurologist for evaluation for AD ANS: A Patients with weight loss, confusion, and lethargy are often dehydrated and this should be evaluated by looking at Hgb and Hct, electrolytes, and BUN. This patient is currently leading an active life, so the likelihood that recent symptoms are related to AD, although this may be evaluated if dehydration is ruled out. Anemia would be a consideration when dehydration is ruled out. Referrals are not necessary unless initial evaluations suggest that malnutrition or AD is present. REF: Dehydration/Pathophysiology/Clinical Presentation/Physical ExaminationTest Bank 2 3. The practitioner is establishing a plan for routine health maintenance for a new female client who is 80 years old. The client has never smoked and has been in good health. What will the practitioner include in routine care for this patient? Select all that apply. a. Annual hypertension screening b. Baseline abdominal aorta ultrasound c. Colonoscopy every 10 years d. One-time hepatitis B vaccine e. Pneumovax vaccine if not previously given f. Yearly influenza vaccine ANS: E, F For older clients a one-time pneumovax is given after age 65. Influenza vaccine should be given every year. Hypertension screening should be performed at each office visit, not just annually. An abdominal aorta US is performed once for every smoking male. Colonoscopy is performed every 10 years after age 50, but not after age 74. REF: Table 13-1: Recommended Screening and ImmunizationsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 14: Palliative and End-of Life Care Test Bank Multiple Choice 1. A patient who is near death is exhibiting signs of agitation, anxiety, and intractable pain. When discussing palliative sedation with this patient’s family, what will be discussed? Select all that apply. a. The chance that refractory symptoms will be alleviated b. The fact that this is an intervention of last resort c. The likelihood that the patient will develop dependence on the drugs d. The need for informed consent from the patient and family e. The possibility that this measure may hasten death ANS: B, D, E Palliative sedation is used as a treatment of last resort for patients whose symptoms are intolerable or refractory. Patients, if possible, and family members must give informed consent. This treatment has the possibility of hastening death by inhibiting respirations. Symptoms will not be alleviated by using the measure. The chance of drug dependence is irrelevant in this situation. REF: Palliative Sedation for Management of Intractable Symptoms in Patients Near Death 2. When should palliative care be initiated by a primary care provider? a. After an ill patient asks for Hospice services b. As part of routine health maintenance c. When a patient is diagnosed with a serious disease d. When an interdisciplinary team is formed to manage a disease ANS: B Palliative care support begins with an understanding of a patient’s preferences and helping the patient to identify goals of care. Health care providers should initiate such discussions as a component of the initial history of adults regardless of age or health status. Palliative care services may be ordered when a patient is diagnosed with a serious disease; waiting until the patient asks for Hospice services or when an interdisciplinary team is formed increases the chances of providing end-of-life care that does not meet the patient’s needs. REF: Palliative Care/Advance Care Planning 3. When using the ―Five Wishes‖ approach to documenting patient preferences for end-of-life care, the provider will document which types of preferences?Test Bank 2 Select all that apply. a. A directive to avoid calling 911 at the time of death b. A specific list of treatments the patient does not want c. How much information to give various family members d. The level of sedation versus alertness the patient desires e. The people designated to make care decisions for the patient ANS: C, D, E The Five Wishes approach addresses the type of care a patient wants as a disease progresses and is less defensive than the traditional advance directive which indicates the type of care a patient does not want. Calling 911 may be done without requiring resuscitation if the patient has an appropriate advanced directive in place. REF: Advance Care PlanningButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 15: Obesity and Weight Management Test Bank Multiple Choice 1. A woman who is obese has a neck circumference of 16.5 cm. Which test is necessary to assess for complications of obesity in this patient based on this finding? a. Electrocardiography b. Gallbladder ultrasonography c. Mammography d. Polysomnography ANS: D Women with a neck circumference greater than 16 cm have an increased risk of obstructive sleep apnea and should have polysomnography to assess for this complication. The other tests may be necessary for obese patients, but are not specific to this finding. REF: Physical Examination/Diagnostics 2. Which medications are associated with weight gain? Select all that apply. a. Antibiotics b. Antidepressants c. Antihistamines d. Insulin analogs e. Seizure medications ANS: B, C, D, E Antidepressants, antihistamines, insulin and insulin analogs, and seizure medications are all associated with weight gain. Antibiotics are not associated with weight gain. REF: Pharmaceuticals Associated with Weight GainButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 16: Lifestyle Management Test Bank Multiple Choice 1. A 60-year-old patient who leads a sedentary lifestyle has expressed an interest in beginning an aerobic exercise program. What will the provider include when counseling this patient about this program? a. Begin with a 45 to 60 minute workout b. Include a 1 to 2 minute warm up before exercise c. Maintain a heart rate between 80 and 128 beats per minute d. Stretching should be performed prior to activity ANS: D The heart rate should be kept between 50% and 80% of the maximum heart rate (220 minus the patient’s age = 160), which is 80 to 128 beats per minute. Patients who are not conditioned should begin with a 20 minute workout; conditioned individuals may increase up to 60 minutes. The warm up should be 3 to 5 minutes and longer if it is cold. Stretching is performed after the activity when the muscles are warm. REF: Exercise 2. Routine screening blood tests at an annual physical exam reveal a fasting glucose level of 125 mg/dL and a hemoglobin A1C of 6.2%. What will the provider do, based on these results? a. Evaluate the patient for impaired glucose tolerance b. Reassure the patient that these are normal values c. Suggest that the patient begin an exercise program d. Tell the patient that these results indicate diabetes ANS: A The fasting blood glucose level is normal, but the HgA1C indicates impaired glucose tolerance. If the HgA1C were greater than 6.4%, the patient would be diagnosed with diabetes. Until the results are evaluated, suggestions for treatment are not indicated. REF: Diabetes 3. The primary care provider is screening a patient using the CAGE criteria. What will the provider include in this assessment? Select all that apply. a. Number of times per week eaten in restaurantsTest Bank 2 b. Sodium and sugar intake c. Sources of daily dairy intake d. Total number of servings of fruits and vegetables e. Types of meats and proteins ANS: A, C, E The CAGE questionnaire is designed to evaluate the intake of saturated fat and cholesterol, so the provider will ask about sources of dairy, the number of times eating foods not made at home, and the types of meats and proteins eaten. The questionnaire does not evaluate for sodium, sugar, fruits, or vegetables. REF: Box 16-1: Dietary CAGE Questions for Assessment of Intake of Saturated Fat and CholesterolButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 17: Routine Health Screening and Immunizations Test Bank Multiple Choice 1. A 50-year-old female patient has a blood pressure of 118/72 mm Hg, a negative family history for breast and ovarian cancer, a normal Pap smear 2 years prior, and a Framingham risk screening within normal limits. Which should be part of this patient’s routine annual well-patient exams? a. Bone mineral density screening b. Breast cancer screening and mammogram c. Cervical cancer screening with a Pap test d. Lipid screening and cholesterol tests ANS: B The American Cancer Society recommends yearly mammogram at age 40. Bone mineral density screening begins at age 50 to 64, based on risk. Cervical cancer screening should be performed every 3 years unless there is increased risk. Lipid screening and cholesterol is performed annually if there is increased risk according to the Framingham guidelines. REF: Table 17-1: Screening Tests for Women/Table 17-4: Comparison of American Cancer Society and USPSTF Screening Guidelines for the Early Detection of Cancer in Asymptomatic Individuals 2. A 55-year-old patient who had influenza in the previous influenza season asks about the flu vaccine. What will the provider tell the patient? a. Having influenza vaccine confers lifetime immunity b. The FluMist vaccine may be used each year c. The Fluzone High-Dose vaccine is recommended d. The trivalent influenza vaccine is indicated annually ANS: D Because the strains of influenza vary from year to year, annual immunization with TIV is indicated for all persons. Lifetime immunity is not conferred with infection. The Flu Mist is used in persons 50 years of age and younger. The Fluzone High-Dose vaccine is used in patients older than 65 year. REF: Influenza Vaccine 3. A 60-year-old patient with a previous history of shingles asks about the herpes zoster vaccine. What will the provider recommend?Test Bank 2 a. A series of two herpes zoster vaccinations b. A single dose of herpes zoster vaccine c. No herpes zoster vaccine is necessary d. Prophylactic vaccination if exposed to chicken pox ANS: B All patients 50 years and older should have a single dose of herpes zoster vaccine regardless of previous herpes zoster infection. REF: Herpes Zoster VaccineButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 18: Principles of Occupational and Environmental Health in Primary Care Test Bank Multiple Choice 1. A patient who has a history of working around asbestos and silica fibers is concerned about developing lung disease. The primary care provider determines that the patient has a previous history of asthma as a child and currently has frequent episodes of bronchitis. A physical examination is normal and pulmonary function tests and radiographs are negative. What action is correct? a. Reassure the patient about the normal findings b. Refer the patient to an occupational health specialist c. Request a workplace environmental assessment d. Suggest that the patient follow up with a pulmonologist ANS: B Patients with environmental exposure may not have symptoms or positive findings. Because this patient reports frequent bronchitis, this should be followed up with an occupational health specialist who can evaluate the degree of exposure and perform further testing. Normal findings are not necessarily reassuring. The occupational specialist may request an environmental assessment. Pulmonologists are not trained in occupational health. REF: Occupational Respiratory Diseases 2. During a pre-placement screening for a person hired for a job requiring heavy lifting, a primary care provider notes that the new employee has environmental allergies, a history of GERD, recurrent eczema, a previous history of an ankle fracture, and normal lower back strength and flexibility. A urine drug screen is negative. What will be included in the report to the employer? Select all that apply. a. GERD history b. History of allergies and eczema c. History of ankle fracture d. Lower back screening results e. Urine drug screening results ANS: D, E Only findings related to the ability of the individual to perform position requirements for the job are included in the report. Other findings should not be included, even though they may need to be addressed. REF: Pre-Placement Health EvaluationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 19: College Health Test Bank Multiple Choice 1. A female freshman college student tells the primary care provider at the student health center that she has a history of anorexia nervosa that has been well-controlled for several years. What will the provider recommend for this student? a. Dietary counseling b. Participation in sports c. Regular weight assessments d. Stress management strategies ANS: D Students with previous eating disorders may regress when stressed, so stress management is essential. Unless she begins to regress, dietary counseling is not indicated. Many who participate in sports will develop eating disorders in order to control weight. It is not necessary to evaluate weight regularly. REF: Eating Disorders and Weight Management 2. A female college student seeks information about emergency contraception. What is the most important part of the assessment of this patient? a. Cultural considerations for use of contraception b. Feelings of guilt about a possible pregnancy c. Possible concerns about confidentiality d. The female’s sense of control in sexual situations ANS: D Because college women are at greater risk for sexual violence and assault, a request for emergency contraception must be followed by an evaluation of possible rape or assault. The other considerations may be part of the assessment, but are not as important as determining whether a rape has occurred. REF: Reproductive, Substance, and Safety IssuesButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 20: Health Care of the International Traveler Test Bank Multiple Choice 1. An international traveler plans to travel to Kenya in sub-Saharan Africa. Which is an important disease precaution for this person? a. Carrying chloroquine to take as needed b. Starting prophylactic doxycycline before travel c. Taking precautions against Chikungunya fever d. Understanding how Ebola virus is transmitted ANS: B Malaria is a greater concern worldwide than Ebola virus and Chikungunya fever, although both are emerging diseases. Travelers should take antimalarial medications and, in this part of Africa, where there is widespread resistance to chloroquine, doxycycline is a better choice as prophylaxis. Even when chloroquine is appropriate, it must be taken prior to travel and not as needed. Chikungunya fever is a disease of the Western Hemisphere, especially in the Caribbean. Ebola virus is epidemic in western Africa and not in Kenya. REF: Introduction/Medications and Prescriptions/Malaria/4: Provider Toolbox for Travelers: Brochures, Vaccines, and Medications 2. A patient returns home from travel in Africa and experiences chronic, non-bloody diarrhea. The patient reports frequent bloating and flatulence with a ―rotten egg‖ smell. What is the treatment for this type of diarrhea? a. Azithromycin b. Ciprofloxacin c. Metronidazole d. Rifampin ANS: C This patient has symptoms characteristic of Giardia lamblia and should be treated with metronidazole. Azithromycin is given for Campylobacter infection, which is a bacterial cause. Ciprofloxacin is used for bacterial infections such as Salmonella or Shigella, which cause bloody diarrhea. Rifampin is used for non-invasive strains of E. coli. REF: Food and Water Precautions and Traveler’s Diarrhea 3. A patient who is planning international travel to a developing country asks the provider about vaccinations. Which is true about pre-travel vaccines?Test Bank 2 a. Country-specific guidelines are provided by individual embassies. b. Malaria vaccine is the most important vaccine for worldwide travel. c. Requirements should be reviewed at least 6 to 8 weeks prior to travel. d. There are at least five required vaccines for entry into certain countries. ANS: C Patients seeking immunizations prior to international travel should have these reviewed at least 6 to 8 weeks prior so that antibody responses and completion of vaccine series may occur. Country-specific guidelines may be found on the CDC website. Malaria is not prevented by vaccine, but by prophylactic antimalarial drugs. There are only two vaccines that are required. REF: Immunizations/Medications and Prescriptions/MalariaButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 21: Presurgical Clearance Test Bank Multiple Choice 1. Which factors determine which diagnostic tests should be performed in a presurgical clearance evaluation? Select all that apply. a. Patient’s age b. Patient’s comorbidities c. Previous surgeries d. Surgeon’s preference e. Type of anesthetic agent planned ANS: A, B, D, E The patient’s age and comorbidities, surgeon preference, and the type of anesthetic planned all determine which presurgical diagnostic tests will be performed. The patient’s previous surgeries do not determine presurgical testing. REF: Diagnostics 2. Which patient should have pulmonary function testing as part of the presurgical exam? a. A patient older than 60 years of age b. A patient undergoing major intra-thoracic surgery c. A patient with a history of pneumonia in the last 2 years d. A patient with diabetes and morbid obesity ANS: B Any patient undergoing major thoracic surgery should have pulmonary function testing. Age over 60 years, a history of pneumonia, and diabetes and obesity do not require pulmonary function testing unless there is comorbid COPD. REF: Table 21-1: Tests for Presurgical ClearanceButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 22: Preparticipation Sports Physical Test Bank Multiple Choice 1. During a pre-participation sports physical, the examiner notes a difference in strength of the patient’s radial and femoral pulses with the femoral pulses being weaker. What will the provider do? a. Evaluate for orthostatic hypotension b. Obtain Doppler studies of lower extremity circulation c. Reassure the patient that this is a normal finding d. Refer the patient for a cardiologic exam ANS: D Differences in strength between radial and femoral pulses may indicate coarctation of the aorta and should be evaluated by a cardiologist. This finding does not indicate orthostatic hypotension. The likelihood of decreased circulation is low in a young athlete. REF: Physical Examination 2. An overweight adolescent who takes metformin has type 2 diabetes with a HgA1c of 8.5% and asks about sports participation. What will the provider recommend? a. Losing weight prior to initiating sports participation b. Participation in strenuous sports to help with weight loss c. Referral to the endocrinologist for sports clearance d. Switching to insulin therapy prior to participation ANS: C Patients with poorly controlled diabetes should be referred to a specialist prior to clearance for sports participation. This patient has an elevated HgA1C, indicating poor control. The endocrinologist may suggest the other options, but the primary care provider should not clear this patient for participation in sports. REF: Medical Clearance 3. A high-school adolescent is being screened for fitness before participating in sports. The adolescent has a normal examination and the examiner notes S1 and S2 heart sounds without murmur, normal blood pressure, and equal pulses. The parent reports that the adolescent’s father has a history or Wolff-Parkinson-White syndrome, which has been treated. What will the provider do? a. Clear the adolescent to play sportsTest Bank 2 b. Perform an electrocardiogram c. Refer the adolescent to a cardiologist d. Tell the adolescent that sports are not allowed ANS: C A positive family history of Wolff-Parkinson-White syndrome requires physician consultation or referral before medical clearance can be given. The adolescent has a normal heart rate and physical exam, so the ECG may not yield significant or useful results. The examiner cannot clear the adolescent without consulting with a specialist. The adolescent may be cleared for sports by the specialist. REF: Medical ClearanceButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 23: Disaster/Emergency Preparedness and Response in Primary Care Test Bank Multiple Choice 1. What is included in the mitigation phase of emergency management? a. Debriefing and review b. Drills and exercises c. Identification of risks d. Use of Incident Command System ANS: C The mitigation phase involves identification of risks. Debriefing and review occurs during the recovery phase. Drills and exercises are part of the preparedness phase. Use of an Incident Command System is part of the response phase. REF: Preparing the Primary Care Office for Small-Scale Emergencies/Disasters 2. A primary care office develops a plan for what to do in case of a fire in the building. As part of the plan, two people are to take charge in case of this emergency. Which phase of emergency planning does this represent? a. Mitigation b. Preparedness c. Response d. Recovery ANS: C The response phase involves identification of those who will be in command in case of an emergency and identification of the roles of other personnel. The mitigation phase involves identification of risks. Debriefing and review occurs during the recovery phase. Drills and exercises are part of the preparedness phase. REF: Preparing the Primary Care Office for SmallScale Emergencies/DisastersButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 24: Acute Bronchospasm Test Bank Multiple Choice 1. A patient with asthma has been given three bronchodilator treatments but continues to have wheezing and shortness of breath. The nurse caring for the patient notes an oxygen saturation of 90% on room air. What action is indicated? a. Administer oxygen and continue to monitor the patient b. Contact the respiratory therapist to administer another treatment c. Notify the patient’s physician immediately d. Reassure the patient that the treatments will take effect soon ANS: C Patients with bronchospasm who have oxygen saturations less than 92% on room air and who fail to improve with nebulizer treatment given three times, need physician consultation. While oxygen administration and further nebulizer treatments may be indicated, it is incorrect to continue to monitor the patient without notifying the physician. REF: Acute Bronchospasm/Physician Consultation 2. Which clinical findings are worrisome in a patient experiencing acute bronchospasm, requiring immediate treatment? Select all that apply. a. A silent chest after previously wheezing b. Decreasing blood pressure c. Presence of an urticarial rash d. Pulsus paradoxus of 10 mm Hg e. Wheezing on both inspiration and expiration ANS: A, B, C A silent chest indicates severe spasm and is an ominous sign. Decreasing blood pressure and urticarial rash are present with anaphylaxis, which is a respiratory emergency requiring oxygen, diphenhydramine or epinephrine. A pulsus paradoxus greater than 25 mm Hg is worrisome. Wheezing on inspiration and expiration is a common finding and not necessarily an emergency. REF: Acute Bronchospasm/Physical Examination/Differential Diagnosis 3. Which symptom in a patient with asthma indicates severe bronchospasm?Test Bank 2 a. Breathlessness with minimal activity or eating b. Pausing to breathe while attempting to talk c. Repetitive, spasmodic coughing at night d. Wheezing after exposure to a trigger ANS: B Inability to speak a full sentence without pausing to breathe indicates severe bronchospasm. Breathlessness, repetitive and spasmodic coughing, and wheezing are all common signs of bronchospasm and do not necessarily indicate severe bronchospasm. REF: Acute Bronchospasm/Clinical PresentationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 25: Anaphylaxis Test Bank Multiple Choice 1. A child with no previous history of asthma is brought to the emergency department with wheezing, stridor, and shortness of breath. When the child is started on oxygen and given a nebulized bronchodilator treatment, the treatment team notes a wheal and flare rash on the child’s trunk. What medication will be given immediately? a. Inhaled racemic epinephrine b. Intramuscular epinephrine c. Intravenous diphenhydramine d. Intravenous ranitidine ANS: B The patient has signs of anaphylaxis and should be given IM or SC epinephrine immediately as first-line therapy, with this repeated every 5 to 20 minutes as needed to prevent cardiovascular shock. Inhaled epinephrine is used for acute upper airway bronchospasm. Diphenhydramine and ranitidine are given as second-line treatment after epinephrine is administered or for mild, nonlife-threatening allergic reactions. REF: Anaphylaxis/Management 2. A man self-administers epinephrine using an Epi-Pen after experiencing a bee sting and developing angioedema and wheezing. What should the man do next? a. Obtain transport to an emergency department immediately b. Repeat the epinephrine dose if needed and notify a physician of the episode c. Resume normal activity if symptom free after 30 to 60 minutes d. Take oral diphenhydramine and report any symptoms to a provider ANS: A The man has a history of anaphylaxis and experienced symptoms after contact with a trigger. The Epi-Pen should be used immediately, but does not prevent the need for follow up in an emergency department for close observation, since continued reaction to the allergen can occur for 6 to 8 hours. The epinephrine dose may be given if needed before emergency personnel arrive, but a second dose is not sufficient to prevent ongoing reaction to the allergen. REF: Anaphylaxis/Management/Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 26: Bites and Stings Test Bank Multiple Choice 1. A patient is seen in the emergency department after experiencing a spider bite. The spider is in a jar and is less than one inch in size, yellow-brown, and has a violin-shaped marking on its back. Depending on the patient’s symptoms, which treatments and diagnostic evaluations may be ordered? Select all that apply. a. Airway management b. An acute abdominal series c. Antivenom therapy d. CBC, BUN, electrolytes, and creatinine e. Coagulation studies f. Tetanus prophylaxis ANS: D, E, F The spider is a brown recluse. If the patient exhibits systemic symptoms, laboratory workup, including CBC, BUN, creatinine, electrolytes, and coagulation studies should be performed. Tetanus prophylaxis is given. Airway management, an acute abdominal series, and antivenom therapy are used for black widow spider bites. REF: Spider Bites/Definition and Epidemiology/Diagnostics/Initial Stabilization and Management 2. A child experiences a snake bite while camping and is seen in the emergency department. The child’s parents are not able to identify the type of snake. An inspection of the site reveals two puncture wounds on the child’s arm with no swelling or erythema at the site. The child has normal vital signs. Which treatment is indicated? a. Administering antivenom and observing the child for 24 to 48 hours b. Cleaning the wound, giving tetanus prophylaxis, and observing for 12 hours c. Performing a type and cross match of the child’s blood d. Referral to a surgeon for incision and suction of the wound ANS: B The child does not have immediate symptoms of envenomation, since there is no swelling or erythema. Because symptoms may be delayed, and the type of snake is unknown, the child should be observed in an ED or hospital for 12 hours after providing wound care and tetanus prophylaxis. Antivenom is not indicated unless envenomation occurs. Type and cross match is done if envenomation is severe. Incision and suction of the sound is not recommended. REF:Test Bank 2 Reptile Bites and Scorpion Stings/Physical Examination/Diagnostics/Initial Stabilization and ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 27: Bradycardia and Tachycardia Test Bank Multiple Choice 1. A patient reports heart palpitations but no other symptoms and has no prior history of cardiovascular disease. The clinic provider performs an electrocardiogram and notes atrial fibrillation and a heart rate of 120 beats per minute. Which is the initial course of action in treating this patient? a. Administer atenolol intravenously b. Admit to the hospital for urgent cardioversion c. Refer the patient to a cardiologist d. Transport the patient to the ED by ambulance ANS: C This patient has no history of serious heart disease and does not have symptoms of chest pressure, acute MI, or congestive heart failure and may be referred to a cardiologist for evaluation and treatment. Atenolol is given IV for patients who are unstable; the advanced life support treatment guidelines do not recommend treatment of tachycardia if the patient is stable. Urgent cardioversion is rarely needed if the heart rate is less than 150 beats per minute unless there are underlying heart conditions. It is not necessary to transport a stable patient to the ED. REF: Tachycardia/Initial Stabilization and Management 2. A patient who takes a beta blocker medication is in the emergency department with syncope, shortness of breath, and hypotension. A cardiac monitor reveals a heart rate of 35 beats per minute. Which medication may be used to stabilize this patient? a. Adenosine b. Amiodarone c. Atropine d. Epinephrine ANS: D Epinephrine is indicated if unstable bradycardia is caused by beta blockers. This patient is symptomatic and unstable and should be treated. Adenosine and amiodarone are used to treat tachycardia. Atropine is used for some types of bradycardia, but not when induced by beta blockers. REF: Bradycardia/Initial Stabilization and ManagementTest Bank 2 3. Which cardiac arrhythmia in an unstable patient requires unsynchronized shocks, or defibrillation? a. Atrial fibrillation b. Atrial flutter c. Monomorphic ventricular tachycardia d. Polymorphic ventricular tachycardia ANS: D Polymorphic ventricular tachycardia should be treated as ventricular fibrillation with unsynchronized shocks. The other arrhythmias are treated with synchronized cardioversion. REF: Box 27-1:Cardioversion and defibrillation of unstable patients with tachycardiaButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 28: Cardiac Arrest Test Bank Multiple Choice 1. Current American Heart Association (AHA) recommendations include: Select all that apply. a. A compression depth of 1½ inches or more on an adult b. A rate of 100 compressions per minute at a minimum c. Rescue breaths given during 2 seconds to allow full chest rise d. Untrained rescuers giving compressions without breaths e. Using a ratio of 2 rescue breaths to 30 compressions ANS: B, D, E The AHA recommends compression rates of at least 100 compressions per minute at a ratio of 2 breaths for every 30 compressions. Untrained rescuers are encouraged to provide chest compressions only. The depth of compressions in adults should be at least 2 inches. Rescue breaths are given over 1 second with full chest rise. REF: Cardiac Arrest/Physical Examination 2. The AHA recommends early CPR and AED use for adult victims of cardiac arrest outside of a hospital setting because most victims have which arrhythmia? a. Atrial fibrillation b. Atrial flutter c. Ventricular fibrillation d. Ventricular tachycardia ANS: C Most victims of cardiac arrest are in ventricular fibrillation, so the AHA considers early defibrillation the most effective treatment for adult victims of cardiac arrest. The other arrhythmias are not usually present in cardiac arrest and are treated with synchronized cardioversion REF: Cardiac Arrest/Initial Stabilization and Management 3. A health care provider in a clinic finds a patient in a room, unresponsive and pale. Which sign should be used to identify the need to initiate cardiopulmonary resuscitation (CPR)? a. Assessment of gasping breaths or not breathing b. Determination of pulselessness or bradycardia c. Evaluation of peripheral perfusion and level of consciousnessTest Bank 2 d. Obtaining a history of previous myocardial infarction ANS: A The AHA recommends initiating CPR if the victim in not breathing or has gasping breaths. Determination of a pulse in an arrest situation can be problematic and the search for a pulse should not delay chest compressions if the patient is gasping for breath or not breathing. Evaluation of peripheral perfusion and LOC is not part of the initial assessment and not used to indicate the need for CPR. A medical history may be obtained after resuscitation is in progress. REF: Cardiac Arrest/Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 29: Chemical Exposure Test Bank Multiple Choice 1. What is true when considering activated charcoal for gastrointestinal decontamination to treat a toxic substance ingestion? a. It acts by enhancing gastric motility to reduce absorption. b. It is administered only through a nasogastric tube. c. It may be used when petroleum distillates are ingested. d. It must be administered within 60 minutes of ingestion. ANS: D Activated charcoal must be given within an hour after ingestion of the toxin. It absorbs ingested substances and reduces absorption and may cause bowel obstruction; it does not increase bowel motility. It may be given orally or by nasogastric tube. Because it is associated with vomiting, it should not be used when caustic substances, alcohols, and petroleum distillates are ingested. REF: Initial Stabilization and Management/Ingestions 2. A lawn maintenance worker is brought to the emergency department after an accident in which a large amount of pesticide was sprayed all over his clothing. He is able to relate the details of the accident to the emergency department personnel. What is the priority treatment on admission? a. Administer intravenous diphenhydramine and possibly epinephrine b. Contact the Poison Control center to ask about appropriate antidotes c. Place ona cardiorespiratory monitor and establish intravenous access d. Remove the patient’s clothing and irrigate the skin for 15 to 30 minutes ANS: D Most skin exposure to chemicals must be treated immediately with copious irrigation with water, so this is the initial priority in a stable patient. Since he is able to converse with staff, he is likely to be stable. If signs of anaphylaxis occur, diphenhydramine and epinephrine are indicated. The Poison Control center should be contacted, but this is not the priority. After irrigation to minimize exposure, other interventions, such as cardiorespiratory monitoring and IV access may be necessary. REF: Initial Stabilization and Management/Skin ExposureTest Bank 2 3. A child is brought to the emergency department because a grandparent suspects ingestion of a tricyclic antidepressant medication found in the bathroom. What symptoms will the ED professionals expect to observe if this is the case? Select all that apply. a. Excessive salivation b. Flushed skin c. Hallucinations d. Hypothermia e. Mydriasis f. Urinary frequency ANS: B, C, E Tricyclic antidepressants will cause anticholinergic effects, including flushing of the skin, hallucinations or psychosis, and mydriasis. These medications also cause dry mucous membranes, hyperthermia, and urinary retention. REF: Chemical Exposure/Clinical PresentationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 30: Electrical Injuries Test Bank Multiple Choice 1. What is true about electrical injuries? Select all that apply. a. Alternating current causes tetanic skeletal muscle contractions. b. Direct current is more dangerous than alternating current. c. Electrical injury causes more tissue necrosis in nerves than other tissues. d. Lightning is less lethal because the duration of electrical strike is short. e. Low-voltage contact has no potential to be lethal. ANS: A, C, D Alternating current tends to be more lethal than direct current because it causes tetanic muscle contractions. Electrical injury affects nerves more than other tissues because nerve tissue has the least resistance to direct flow and is most easily damaged. Lightning, although it has a voltage of 10 million to 2 billion volts, has a short duration of contact. Alternating current is more dangerous than direct current. Low-voltage contact has the potential to be lethal. REF: Pathophysiology 2. An adolescent male has an electrical injury from a high-voltage wire after climbing a tree. Which initial diagnostic test is necessary? a. 12-lead electrocardiogram b. Cervical spine radiography c. Complete blood count and electrolytes d. Creatine kinase and myoglobin level ANS: A An early essential assessment in all patients with electrical injury is a 12-lead ECG to assess arrhythmias and conduction disturbances. The other labs are part of the initial workup, but not a priority over the ECG. A C-spine radiograph is done if cervical injury is suspected. REF: Physical Examination/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 31: Environmental Allergies Test Bank Multiple Choice 1. When performing diagnostic tests to determine which environmental allergens cause symptoms in an atopic patient, which aspects of scratch testing are preferable to other methods? Select all that apply. a. It has a lower potential for anaphylaxis. b. It is more sensitive. c. It is safer. d. It produces more rapid results. e. It requires a stepwise approach. ANS: A, C, D Scratch testing involves scratching the surface of the skin. This method has a lower potential for anaphylaxis, is safer, and has more rapid results. It is not as sensitive as the intradermal method, which requires a stepwise approach. REF: Environmental Allergies/Diagnostics 2. Which immunoglobulin is responsible for initiating the allergic cascade in susceptible individuals who are exposed to allergens? a. IgG b. IgA c. IgM d. IgE ANS: D While IgA, IgG, and IgM are produced to appropriately protect the body, circulating levels of IgE are responsible for the atopic reaction. REF: Environmental Allergies/Pathophysiology 3. Which food allergies in children may beoutgrown in the first decadeof life? Select all that apply. a. Egg allergy b. Fish allergy c. Milk allergy d. Nut allergyTest Bank 2 e. Shell fish allergy ANS: A, C Both egg and milk allergy may be outgrown within the first decade of life. Fish, nut, and shell fish allergies are more common in adults and have a higher incidence of lifetime allergy. REF: Food Allergies/Definition and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 32: Head Trauma Test Bank Multiple Choice 1. A patient is in the emergency department after sustaining a blow to the head in a motor vehicle accident. The patient’s Glasgow Coma score is 14 and the patient is drowsy. The patient has a small amount of blood in one external auditory canal. Which is a priority in diagnosing the extent of injury in this patient? a. Close monitoring of pulse, respiration, and oxygenation b. Continued assessment of neurological status c. Magnetic resonance imaging of the head d. Non-enhanced computed tomography of the head ANS: D Although this patient’s GCS is non-concerning, the type of injury and the sign of blood in the external auditory canal put this patient at high risk for skull fracture, so a head CT is indicated immediately. Close monitoring of vital signs and neurological status should be continuously performed, the CT is a priority to help determine the treatment needed. MRI is not especially useful, but may be performed after CT if more detail of structures is needed. REF: Head Trauma/Diagnostics 2. A patient who sustained a head injury has a Glasgow Coma score of 14. The patient’s spouse reported that the patient lost consciousness for approximately 7 minutes after falling down the stairs. A head CT does not reveal brain lesions. Which treatment is indicated? a. Admission to the hospital with a neurosurgical evaluation b. Continued observation in the emergency department until stability is ensured c. Discharge to home with close observation by the patient’s spouse for 24 hours d. Dismissal to home with a referral for follow up with a neurologist ANS: A This patient had loss of consciousness longer than 5 minutes and has a GCS of 14; both of these are indications for admission to the hospital with a neurosurgery consult, even though the CT is currently normal. REF: Head Trauma/Disposition and Referral 3. A patient is brought to the emergency department after being hit in the head with a baseball. The patient is awake and talking, but is confused and disoriented and does not obey simple commands. The patient is able to point to the area of pain and opens eyes only whenTest Bank 2 commanded to do so. Bystanders report a period of unconsciousness lasting almost 5 minutes. Which severity of traumatic brain injury is likely? a. Normal b. Mild c. Moderate d. Severe ANS: C This patient’s Glasgow Coma score is 11, based on eye opening to verbal command (3), ability to localize pain (4), and conversing while confused (4). The patient was unconscious less than 10 minutes, which usually indicates less severe injury. A patient with a GCS between 9 and 12 with or without loss of consciousness is considered to have a moderate head injury. REF: Head Trauma/Definition and Epidemiology/Table 32-1: Glasgow Coma ScaleButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 33: Hypotension Test Bank Multiple Choice 1. A young adult patient is being treated for hypertension and is noted to have a resting blood pressure of 135/88 mm Hg just after finishing a meal. After standing, the patient has a blood pressure of 115/70 mm Hg. What is the likely cause of this change in blood pressure? a. A hyperglycemic episode b. Antihypertensive medications c. Neurogenic orthostatic hypotension d. Postpriandal hypotension ANS: B Medications to treat hypertension may cause orthostatic hypotension. Hypoglycemia may cause hypotension. Neurogenic orthostatic hypotension is less likely. Postpriandal hypotension occurs in elderly patients. REF: Pathophysiology 2. An elderly patient who has orthostatic hypotension secondary to antihypertensive medications is noted to have a drop in systolic blood pressure of 25 mm Hg. Which intervention is important for this patient? a. Administration of intravenous fluids b. Close monitoring cardiorespiratory status c. Initiation of a fall risk protocol d. Withholding antihypertensive medications ANS: C A reduction of systolic blood pressure >20 mm Hg is a risk factor for falls in the elderly, so a fall risk protocol should be initiated. Unless the patient is dehydrated, IV fluids are not recommended. Close monitoring of CR status will not prevent falls. Withholding antihypertensive medications often worsens orthostatic hypotension. REF: Diagnostics/Management 3. An older patient develops orthostatic hypotension secondary to an antihypertensive medication and asks what measures can be taken to minimize this condition. What will the provider recommend? Select all that apply.Test Bank 2 a. Crossing the legs when standing up b. Custom-fitted elastic stockings c. Discontinuation of the medication d. Increased physical activity e. Performing the Valsalva maneuver ANS: A, B, D Measures such as crossing the legs when standing, wearing custom-fitted elastic stockings, and increasing physical activity may all help prevent orthostatic hypotension symptoms. Discontinuation of the medication may make the condition worse. Performing the Valsalva maneuver will increase intrathoracic pressure and should be avoided. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 34: Poisoning Test Bank Multiple Choice 1. A patient who ingested a bottle of acetaminophen tablets is brought to the emergency department. Which treatment is indicated? a. Flumazenil b. N-acetylcysteine c. Naloxone d. Supportive care only ANS: B N-acetylcysteine is used as an antidote for acetaminophen overdose. Flumazenil is used to treat benzodiazepine overdose. Naloxone is given for opioid overdose. REF: Poisoning/Initial Stabilization and Management 2. Several groups of college students arrive in the emergency department reporting severe gastrointestinal symptoms after leaving a fraternity party. After stabilizing these patients, a priority for the emergency department personnel is to a. contact the fraternity to determine whether others are affected. b. isolate the patients to prevent spread of infection. c. notify the local health department about this outbreak. d. obtain histories from the patients about illicit drug use. ANS: A Providers must be alert to situations in which a number of people present with similar symptoms within a short time, suggesting a common source of poisoning. This lowered threshold of suspicion requires action to prevent additional casualties, so the providers should contact the fraternity. If an infectious cause is determined, isolation may be required, but an investigation of the common source is paramount. After the situation is stabilized, the health department should be notified. Because the symptoms appeared in a cluster of patients who all attended the same party, questioning them about illicit drug use is a lower priority than determining risk to others. REF: Poisoning/Clinical Presentation 3. What is the first priority in emergency management of a biological terrorism attack? a. Basic life supportTest Bank 2 b. Communication with authorities c. Containing the exposures d. Informing the public of the risk ANS: C In a bioterrorism attack, the initial priority is to contain the exposures and prevent expansion of the event to others. Basic life support is the second priority and close communication with authorities is the third priority. Informing the public is a later priority after the situation has been stabilized. REF: TerrorismButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 35: Sexual Assault Test Bank Multiple Choice 1. A patient who was sexually assaulted one month prior tells her provider that she is concerned about contracting HIV. When is it appropriate to perform testing? a. Immediately and then every 6 months for the first year b. Immediately with definitive results c. In two weeks and then 3 to 6 months after the assault d. Three to 6 months after the assault ANS: C Because of the length of time for seroconversion to occur, patients concerned about HIV exposure should be tested 6 weeks after and then 3 to 6 months after the assault. Immediate results will not provide accurate information. The initial testing should be 6 weeks after potential exposure. REF: Sexual Assault/Diagnostics 2. During a health maintenance examination, 17-year-old female reports having been raped repeatedly at a college party during the previous semester and tells the practitioner that she did not seek help at the time. Which action is a priority for the primary care provider? a. Recommending counseling at a local mental health center b. Referring the patient to the emergency department for STI testing c. Reporting the alleged assault to law enforcement d. Suggesting that the patient report the incident to the school ANS: C Any sexual assault perpetrated on a victim younger than 18 years must be reported to the local child or adult protective agency as well as to law enforcement, regardless of whether the patient reports that sexual assault occurred. Counseling, STI testing, and reporting the incident to the school are important, but are not the priority. REF: Sexual Assault/Indications for Referral or Hospitalization 3. When beginning a health maintenance exam, the health care provider learns that an adult patient has been sexually assaulted the previous day. What is the initial responsibility of the provider? a. Notify the police and encourage the patient to press criminal chargesTest Bank 2 b. Perform a thorough gynecological exam and obtain cultures c. Question the patient about the events surrounding the assault d. Refer the patient to the emergency department for a forensic examination ANS: D If a patient has been sexually assaulted within the past 5 days, and especially if within the previous 72 hours, the provider should defer a physical examination and refer the patient to the ED for a forensic examination. It is not necessary to notify the police unless the victim is a child, elderly, or disabled. The provider should not perform the exam – a forensic exam ensures that standard protocol is followed and appropriate evidence is obtained. Retelling the story of the assault may be traumatizing to the patient, so this should be left to providers performing the forensic exam. REF: Sexual Assault/Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 36: Syncope Test Bank Multiple Choice 1. Which tests are indicated as part of the initial evaluation for women of childbearing age who report syncope? Select all that apply. a. 12-lead electrocardiogram b. Cardiac enzyme levels c. Complete blood count d. Electroencephalogram e. Serum glucose testing ANS: A, C, E Initial evaluation for all patients reporting syncope should include a standard 12-lead ECG. Women of childbearing age should have a CBC, serum pregnancy test, and serum glucose testing. Cardiac enzyme levels are obtained if the patient has cardiac risk factors. EEG is performed only if there is a concern for seizure disorder. REF: Syncope/Diagnostics 2. A healthy 20-year-old patient reports having had 1 or 2 episodes of syncope without loss of consciousness. Which is the most likely type of syncope in this patient? a. Cardiac b. Neurogenic c. Orthostatic hypotensive d. Reflex syncope ANS: D Neurally mediated or reflex syncope is the most common cause of syncope and is primarily seen in young adults. Cardiac, neurogenic, and orthostatic syncope are generally seen in older adults. REF: Syncope/Pathophysiology 3. An elderly patient reports experiencing syncope each morning when getting out of bed. Which assessment will the health care provider perform first to evaluate this patient’s symptoms? a. Cardiac enzyme levels b. ElectroencephalogramTest Bank 2 c. Fasting blood glucose d. Orthostatic blood pressures ANS: D Orthostatic blood pressures should be measured first since this patient reports problems associated with rising from a supine position. The other tests are performed as part of the diagnostic workup only if indicated by associated symptoms or suspected causes. REF: Syncope/Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 37: Thermal Injuries Test Bank Multiple Choice 1. A child is brought to the emergency department after getting lost while camping on a cold, rainy day. The child is lethargic on admission. The cardiorespiratory monitor shows a normal heart rate and rhythm, a respiratory rate of 8 to 10 breaths per minute, and a normal blood pressure. The assessment reveals erythema and edema of the child’s hands and feet. What treatments are indicated? Select all that apply. a. Administer antibiotics b. Apply warmed blankets c. Elevate the child’s extremities d. Massage the hands and feet e. Remove all clothing ANS: B, C, E The child has signs of frostbite without other systemic signs. Warming with warm blankets is indicated. The affected areas should be elevated, but not massaged or rubbed. The providers should remove the child’s clothing which may be restrictive or wet and examine the child’s entire skin surface for other signs of frostbite. Antibiotics are not given unless signs of infection are present. REF: Frostbite/Management 2. A patient is brought to a clinic after fainting while working outdoors on a hot day. The patient has slurred speech and headache and has a temperature of 104° F. What will the provider do? a. Administer antipyretic medications to reduce the temperature b. Administer intravenous fluids in the clinic and monitoring response c. Rehydrate the patient with oral fluids containing electrolytes d. Transport the patient to the emergency department ANS: D This patient has CNS signs and an elevated temperature with a history consistent with heat stroke. This patient should be immediately transported to an emergency department. Antipyretic medications are not useful for treating thermal injury. The patient will be given IV fluids and electrolytes in the ED. Oral rehydration is not indicated. REF: Clinical Presentation/ManagementTest Bank 2 3. A provider attending a soccer match on a hot day is assisting a player who feels hot and appears dehydrated, but who is alert and oriented. What does the provider suspect? a. Heat cramps b. Heat exhaustion c. Heat stroke d. Heat syncope ANS: B Heat exhaustion is present when patients have excessive sweating accompanied by sodium and water loss. Heat cramps involve muscle pains or spasms. Heat stroke causes a core body temperature of >106° F. Heat syncope causes fainting or dizziness. REF: Definition and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 38: Examination of the Skin and Approach to Diagnosis of Skin Disorders Test Bank Multiple Choice 1. When examining a patient’s skin, a practitioner uses dermoscopy in order to Select all that apply. a. accentuate changes in color of pathologic lesions by fluorescence. b. assess changes in pigmentation throughout various lesions. c. determine whether lesion borders are regular or irregular. d. differentiate fluid masses from cystic masses in the epidermis. e. visualize skin fissures, hair follicles, and pores in lesions. ANS: B, C, E Dermoscopy is used to visualize the epidermis and superficial dermis and can reveal changes in pigmentation throughout lesions, whether borders are regular or irregular, and the various fissures, follicles, and pores present in lesions. The Wood’s light, or black light, is used to fluoresce lesions to accentuate changes in color. A direct light source is useful for differentiating fluid masses from cystic masses. REF: Physical Examination 2. A primary care provider is performing a Tzanck test to evaluate possible herpes simplex lesions. To attain accurate results, the provider will a. blanch the lesions while examining them with a magnifying glass. b. gently scrape the lesions with a scalpel onto a slide. c. perform a gram stain of exudate from the lesions. d. remove the top ofthe vesicles and obtain fluid from the lesions. ANS: D The Tzanck test requires removing the tops from vesicular lesions in order to obtain fresh fluid from the base of the lesions. Blanching of blue to red lesions under a microscope helps to evaluate whether blood is in the capillaries of the lesions. Scraping lesions onto a slide is done to evaluate the presence of hyphae and spores common with candidiasis or fungal infections. Gram staining is performed to distinguish gram-positive from gram-negative organisms in suspected bacterial infections. REF: Box 38-1: Skin Examination TechniqueButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 39: Surgical Office Procedures Test Bank Multiple Choice 1. A provider is preparing to administer electrocautery to a patient who has several seborrheic keratoses. The patient tells the provider that he has a pacemaker. Which action is correct? a. Administer the electrocautery per the usual protocol b. Apply electrocautery in short burst at low voltage c. Refer the patient to a dermatologist for removal d. Suggest another method for removal of the lesions ANS: B Patients with pacemakers or implantable cardioverter-defibrillators may receive electrocautery if appropriate precautions, such as lower voltage and shorter bursts are taken. It is not necessary to suggest another method or to refer to a dermatologist. REF: Electrocautery 2. A patient has molluscum contagiosum and the provider elects to use cryosurgery to remove the lesions. How will the provider administer this procedure? a. Apply one freeze-thaw cycle to each lesion b. Apply two or more freeze-thaw cycles to each lesion c. Apply until the freeze spreads laterally 1 mm from the lesion edges d. Apply until the freeze spreads laterally 4 mm from the lesion edges ANS: A For molluscum contagiosum, one freeze-thaw cycle is usually sufficient. Two freeze-thaw cycles are generally required for thicker, more keratotic lesions. The freeze should spread laterally 3 to 4 mm from the edge of the lesions. REF: Cryosurgery 3. Which type of office surgical procedure warrants sterile technique? a. Curettage b. Punch biopsy c. Scissor excision d. Shave biopsy ANS: BTest Bank 2 Punch biopsy requires sterile technique. The other procedures require cleaning with alcohol and clean technique with universal precautions. REF: BiopsyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 40: Principles of Dermatologic Therapy Test Bank Multiple Choice 1. An infant has atopic dermatitis and seborrheic dermatitis with lesions on the forehead and along the scalp line. Which is correct when prescribing a corticosteroid medication to treat this condition? a. Initiate treatment with 0.1% triamcinolone acetonide (Kenalog lotion) b. Monitor the infant closely for systemic adverse effects during use c. Place an occlusive dressing over the medication after application d. Prescribe 0.05% fluocinonide (Lidex-E Cream) to apply liberally ANS: A Treatment with 0.1% triamcinolone acetonide is appropriate in this case, because it is a class V corticosteroid and may be used on the face and is suggested for use for these conditions. Systemic side effects are rare when topical corticosteroids are used appropriately. Occlusive dressings increase the risk of adverse effects and are not recommended. 0.05% fluocinonide is a class III corticosteroid and should not be used on the face. REF: Topical Corticosteroids/Table 40-3: Topical Corticosteroids Ranked by Potency/Table 40-4: Suggested Strength of Topical Steroids to Initiate Treatment 2. When recommending an over-the-counter topical medication to treat a dermatologic condition, which instruction to the patient is important to enhance absorption of the drug? a. Apply a thick layer of medication over the affected area b. Place an occlusive dressing over the medication c. Put cool compresses over the affected area after application d. Use a lotion or cream instead of an ointment preparation ANS: B Drug absorption may be enhanced up to 10 times with application of occlusive dressings. Applying a thicker layer does not increase skin penetration or effectiveness of a medication. Warm or inflamed skin absorbs medications more readily; cool compresses will decrease absorption. Lotions and creams are not as readily absorbed as ointments, which have occlusive properties. REF: Dermatologic Vehicles 3. A provider is prescribing a topical dermatologic medication for a patient who has open lesions on a hairy area of the body. Which vehicle type will the provider choose when prescribing this medication?Test Bank 2 a. Cream b. Gel c. Ointment d. Powder ANS: B Gels are an excellent vehicle for use on hairy areas of the body. Creams and ointments are not recommended for hairy areas. Powders should be avoided in open wounds. REF: Dermatologic Vehicles/Table 40-2:Common Vehicles for Topical Pharmacotherapeutic PreparationsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 41: Screening for Skin Cancer Test Bank Multiple Choice 1. Curing a total body skin examination for skin cancer, the provider notes a raised, shiny, slightly pigmented lesion on the patient’s nose. What will the provider do? a. Consult with a dermatologist about possible melanoma b. Reassure the patient that this is a benign lesion c. Refer the patient for possible electrodessication and curettage d. Tell the patient this is likely a squamous cell carcinoma ANS: C This lesion is characteristic of basal cell carcinoma, which is treated with electrodessication and curettage. Melanoma lesions are usually asymmetric lesions with irregular borders, variable coloration, >6 mm diameter, which are elevated; these should be referred immediately. All suspicious lesions should be biopsied; until the results are known, the provider should not reassure the patient that the lesion is benign. Squamous cell carcinoma is roughened, scaling, and bleeds easily. REF: Physical Examination/Management 2. What is the initial approach when obtaining a biopsy of a potential malignant melanoma lesion? a. Excisional biopsy b. Punch biopsy c. Shave biopsy d. Wide excision ANS: A A suspected malignant melanoma lesion should be biopsied with excisional biopsy; if diagnosed, a wide excision should follow. Punch and shave biopsy procedures are appropriate for diagnostic evaluation of NMSC lesions. REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 42:Acne Vulgaris Test Bank Multiple Choice 1. A patient has acne and the provider notes lesions on half of the face, some nodules, and two scarred areas. Which treatment will be prescribed? a. Oral clindamycin for 6 to 8 weeks b. Oral isotretinoin c. Topical benzoyl peroxide and clindamycin d. Topical erythromycin ANS: C This patient has moderate acne, based on symptoms of lesions on half of the face with nodules and a few scars. A combination of topical benzoyl peroxide and clindamycin is recommended. Oral antibiotics are reserved for severe cases. Oral isotretinoin is used only for recalcitrant cases which are severe and have not responded to other treatments. Topical antibiotics should be used as monotherapy. REF: Acne Vulgaris/Pathophysiology/Management 2. When counseling a patient with rosacea about management of this condition, the provider may recommend Select all that apply. a. applying a topical steroid. b. avoiding makeup. c. avoiding oil-based products. d. eliminating spicy foods. e. exposing the skin to sun. f. using topical antibiotics. ANS: C, D, F Patients with rosacea should avoid oil-based products and eliminate spicy foods, alcohol, and hot fluids. Topical antibiotics may be used if pustules are present. Topical steroids are not recommended. Patients do not need to avoid makeup and should avoid the sun. REF: Rosacea 3. A provider is considering an oral contraceptive medication to treat acne in an adolescent female. Which is an important consideration when prescribing this drug? a. A progesterone-only contraceptive is most beneficial for treating acne.Test Bank 2 b. Combined oral contraceptives are effective for non-inflammatory acne only. c. Oralcontraceptives are effective because of their androgen enhancing effects. d. Yaz, Ortho Tri-Cyclen, and Estrostep are approved for acne treatment. ANS: D Three oral contraceptives have a labeled use for acne treatment: Yaz, Ortho Tri-Cyclen, and Estrostep. Progesterone-only contraceptives may worsen acne. Combined oral contraceptives are effective in reducing inflammatory and non-inflammatory acne. Oral contraceptives are effective because of their antiandrogen effects, since androgen induces sebum production. REF: Acne Vulgaris/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 43: Alopecia Test Bank Multiple Choice 1. A patient is in the clinic with patches of hair loss. The provider notes several welldemarcated patches on the scalp and eyebrows without areas of inflammation and several hairs within the patch with thinner shafts near the scalp. Based on these findings, which type of alopecia is most likely? a. Alopecia areata b. Anagen effluvium c. Cicatricial alopecia d. Telogen effluvium ANS: A These findings are characteristic of alopecia areata. Anagen effluvium and telogen effluvium both result in diffuse hair loss and not discrete patches. Cicatricial alopecia involves inflammation. REF: Physical Examination 2. A patient with alopecia is noted to have scaling on the affected areas of the scalp. Which confirmatory test(s) will the provider order? a. Examination of scalp scrapings with potassium hydroxide b. Grasping and pulling on a few dozen hairs c. Serum iron studies and a complete blood count d. Venereal Disease Research Laboratory (VDRL) test ANS: A Scaling on the scalp is suggestive of tinea capitis. To confirm this, the provider will perform scalp scraping or test hair samples with KOH preparation to look for hyphae. Grasping and pulling on hairs is used to identify anagen or telogen hairs by appearance. Serum iron and a CBC are used if anemia is suspected as a cause. VDRL is performed if syphilis is suspected. REF: Diagnostics 3. A female patient is diagnosed with androgenetic alopecia. Which medication will the provider order? a. Anthralin b. CyclosporineTest Bank 2 c. Finasteride d. Minoxidil ANS: D Either minoxidil or finasteride are used for androgenetic alopecia, but finasteride is Pregnancy Category X, so minoxidil is the only medication approved by the FDA for use in women. Anthralin and cyclosporine are used to treat alopecia areata. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 44: Animal and Human Bites Test Bank Multiple Choice 1. Which type of bite is generally closed by delayed primary closure? Select all that apply. a. Bites to the face b. Bites to the hand c. Deep puncture wounds d. Dog bites on an arm e. Wounds 8 hours old ANS: B, C, E Cat and human bites, deep puncture wounds, clinically infected wounds, wounds more than 6 to 12 hours old, and bites to the hand should be left open and closed by delayed primary closure. A bite to the face is closed by primary closure. Dog bites do not require delayed or secondary closure. REF: Management 2. A patient has been bitten by a dog and has sustained several puncture wounds near the thumb of one hand. The patient is able to move all fingers and the bleeding has stopped. What is the correct treatment for this patient? a. Begin rabies and tetanus prophylaxis and bandage the wound b. Clean the wound thoroughly and order a topical antibiotic c. Obtain a physician consultation for evaluation and treatment d. Prescribe oralantibiotics and have the patient follow up in a few days ANS: C Any animal bites on the face or hand require physician consultation because of the increased risk for osteomyelitis, tendinitis, and septic arthritis. The other interventions may or may not be appropriate, but must be decided by the consulting physician. REF: Definition and Epidemiology/Physician Consultation 3. A patient has sustained a human bite on his hand during a fist fight. Which is especially concerning with this type of bite injury? a. Possible exposure to rabies virus b. Potential septic arthritis or osteomyelitisTest Bank 2 c. Sepsis from Capnocytophaga canimorsus infection d. Transmission of human immunodeficiency virus ANS: B Clenched-fist injury, or ―fight bite,‖ has a high complication rate from the high penetrating force with the potential for osteomyelitis, tendinitis, and septic arthritis. Humans do not transmit rabies unless infected, which is highly unlikely. Humans do not transmit C. canimorsus. HIV transmission is potential, but the risk is extremely low. REF: Definition and Epidemiology/PathophysiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 45:Bullous Pemphigoid Test Bank Multiple Choice 1. An elderly adult patient with bullous pemphigoid is prescribed oral prednisone and hydroxyzine to manage symptoms. Which medication side effect is of immediate concern for this patient? a. Osteoporosis b. Pruritis c. Sedation d. Weight gain ANS: C Older patients should take hydroxyzine cautiously because of the risks of sedation. Osteoporosis and weight gain are long-term effects of prednisone and not of immediate concern. Hydroxyzine is given to treat pruritus. REF: Management 2. A patient is newly diagnosed with bullous pemphigoid and has moderate to severe itching. The provider orders a topical corticosteroid will discuss which potential complication with this patient? a. Bone marrow suppression b. Developing systemic lesions c. Secondary infection d. Spread of disease to others ANS: C Topical corticosteroids and excessive rubbing and trauma to skin increase the risk of secondary infections. Bone marrow suppression is a side effect of immunosuppressive therapy. Systemic lesions are not likely; patients may develop systemic infection if secondary infection occurs. The disease is not contagious. REF: Patient and Family Education 3. When assisting with a skin biopsy of a patient suspected of having bullous pemphigoid lesions, the practitioner will a. avoid contact with the infected lesions. b. elicit a positive Nikolsky sign to confirm the diagnosis. c. perform direct immunofluorescence microscopy.Test Bank 2 d. prevent spread of the lesions to other areas of the skin. ANS: C Direct immunofluorescence microscopy is the gold standard for diagnosis of BP. The lesions are not infected. The Nikolsky sign will be negative in patients with BP. The lesions do not spread by this manner. REF: Clinical Presentation and Physical Examination/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 46: Burns (Minor) Test Bank Multiple Choice 1. A patient comes to the clinic after being splashed by boiling water while cooking. The patient has partial thickness burns on both forearms, the neck, and the chin. What will the provider do? a. Clean and dress the burn wounds b. Ordera CBC, glucose, and electrolytes c. Perform a chest radiograph d. Refer the patient to the emergency department ANS: D Patients with burns on the face, potential circumferential burns, and any patient at risk of airway compromise should be referred to the ED for evaluation and treatment. The provider should do this urgently and not clean and dress the wounds or order diagnostic tests. REF: Definition and Epidemiology 2. A patient suffers chemical burns on both arms after a spill at work. What is the initial action by the providers in the emergency department? a. Begin aggressive irrigation of the site b. Contact the poison control center c. Remove the offending chemical and garments d. Request the Material Safety Data information ANS: C The initial response to a chemical burn is to remove the patient’s clothing and the offending chemical. Aggressive irrigation is usually recommended next, but providers should first determine the source to make sure that it is safe to use water. Contacting Poison Control and getting MSDS information are useful measures after the clothing and chemical is removed. REF: Chemical Burns/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 47: Cellulitis Test Bank Multiple Choice 1. A patient with a purulent skin and soft tissue infection (SSTI). A history reveals a previous MRSA infection in a family member. The clinician performs an incision and drainage of the lesion and sends a sample to the lab for culture. What is the next step in treating this patient? a. Apply moist heat until symptoms resolve b. Begin treatment with amoxicillin-clavulanate c. Prescribe oral clindamycin d. Wait for culture results before ordering an antibiotic ANS: C Because of a history of exposure to MRSA, the patient is likely to be colonized and should be treated accordingly. Small lesions may be treated with moist heat, but the likelihood of MRSA requires treatment. Amoxicillin-clavulanate is not effective for MRSA. Treatment should be started empirically. REF: Clinical Presentation/Management 2. A previously healthy patient has an area of inflammation on one leg which has welldemarcated borders and the presence of lymphangitic streaking. Based on these symptoms, what is the initial treatment for this infection? a. Amoxicillin-clavulanate b. Clindamycin c. Doxycycline d. Sulfamethoxazole-trimethoprim ANS: A This patient has symptoms consistent with erysipelas, which is commonly caused by staphylococcal or streptococcal bacteria. These may be treated empirically with a penicillinaseresistant penicillin. Clindamycin, doxycycline, and sulfamethoxazole-trimethoprim are used for methicillin-resistant staphylococcus aureus infections. REF: Clinical Presentation/Management 3. A child has vesiculopustular lesions around the nose and mouth with areas of honey-colored crusts. The provider notes a few similar lesions on the child’s hands and legs. Which treatment is appropriate for this child? a. Amoxicillin-clavulanateTest Bank 2 b. Culture and sensitivity of the lesions c. Sulfamethoxazole-trimethoprim d. Topical antiseptic ointment ANS: A This child has symptoms of impetigo which has spread to the hands and legs. A systemic penicillinase-resistant penicillin is recommended. It is not necessary to obtain a culture since this can be treated empirically in most cases. MRSA is unlikely, so sulfamethoxazole-trimethoprim is not indicated. Oral antibiotics, not topical antiseptics, are the treatment of choice. REF: Clinical Presentation/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 48: Contact Dermatitis Test Bank Multiple Choice 1. A child has irritant contact dermatitis with lesions on the extremities and face. Which treatment is recommended for this patient? a. Antihistamines b. Medium- to high-potency topical corticosteroids c. Oral corticosteroids d. Topical calcineurin inhibitors ANS: C When periorbital regions or more than 20% of the body surface area is involved, the use of an oral steroid is appropriate. Antihistamines produce relaxation and improve sleep, but do not reduce the pruritus associated with contact dermatitis. Topical calcineurin inhibitors may be used in place of topical steroids, but oral steroids are indicated in this instance. REF: Management 2. A patient who has been exposed to poison ivy presents with inflammation and a vesicular rash on one arm. The provider recommends a topical steroid, but the next day the patient calls to report similar lesions appearing on the face. What will the provider tell this patient? a. The rash is spreading through self-inoculation. b. The vesicles may continue to develop for up to 2 weeks. c. The rash may spread over the next 8 weeks. d. The patient must have been re-exposed to the irritant. ANS: B Exposure to poison ivy resin results in vesicles and bullae that develop for up to 2 weeks. Once the resin is washed off, no further spread occurs. With insufficient treatment, the rash may persist, but not spread, for up to 8 weeks. REF: Clinical Presentation and Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 49: Corns and Calluses Test Bank Multiple Choice 1. A patient develops a corn on the dorsolateral aspect of the fifth toe on one foot. What will the practitioner do initially to treat this condition? a. Apply a 40% salicylic acid plaster over the lesion for 48 to 72 hours b. Gently pare the lesion with a No. 15 scalpel blade c. Obtain a foot radiograph to assess underlying bone structures d. Recommend trying an over-the-counter corn solution ANS: B Treatment for corns begins by decreasing the size of the callus or corns using a No. 15 scalpel blade. After decreasing the size, salicylic acid is applied for 48 to 72 hours before paring the remaining tissue. Foot radiographs may be performed if treatment fails. OTC solutions are not generally recommended. REF: Management 2. A patient with a soft corn develops an infection without surrounding erythema or edema. Which treatments are recommended? Select all that apply. a. Oral erythromycin b. Salicylic acid patch c. Sanding with a pumice stone d. Topical mupirocin e. Twice-daily warm soaks ANS: D, E Soft corn infections are treated with twice-daily warm soaks and application of topical mupirocin. If signs of cellulitis are present, an oral antibiotic may be added. Salicylic acid patches are used as part of corn removal. Pumice stones are used to reduce the size of calluses. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 50: Cutaneous Herpes Test Bank Multiple Choice 1. A patient who has recurrent, frequent genital herpes outbreaks asks about therapy to minimize the episodes. What will the provider recommend as first-line treatment? a. Acyclovir b. Famciclovir c. Topical medications d. Valacyclovir ANS: A All three oral antiviral medications help reduce the number of occurrences and the frequency of asymptomatic shedding. Famciclovir and valacyclovir are more costly and no more effective, so should not be first-line therapy. Topical medications are not useful with recurrent, frequent genital herpes. REF: Suppression of Frequent Recurrences 2. A patient who has never had an outbreak of oral lesions reports a burning sensation on the oral mucosa and then develops multiple painful round vesicles at the site. A Tzanck culture confirms HSV-1 infection. What will the provider tell the patient about this condition? a. Antiviral medications are curative for oral herpes. b. The initial episode is usually the most severe. c. There are no specific triggers for this type of herpesvirus. d. Transmission to others occurs only when lesions are present. ANS: B In herpesvirus outbreaks, the initial episode is generally the most severe. Antiviral medications may prevent outbreaks, but do not cure the disease. HSV-1 has several specific triggers. Transmission to others may occur even when lesions are not present. REF: Cutaneous Herpes/Pathophysiology/Clinical Presentation/Management/Patient and Family Education 3. A patient who has had lesions for several days is diagnosed with primary herpes labialis and asks about using a topical medication. What will the provider tell this patient? a. Oral antivirals are necessary to treat this type of herpes. b. Preparations containing salicylic acid are most helpful. c. Topical medications can have an impact on pain and discomfort.Test Bank 2 d. Topical medications will significantly shorten the healing time. ANS: C Topical medications may alleviate discomfort, but do not shorten healing time. Oral antivirals may help shorten healing, but are not necessary as treatment, since the disease is usually selflimiting. Salicylic acid should not be used because it can erode the skin. REF: Primary Herpes LabialisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 51: Dermatitis Medicamentosa Test Bank Multiple Choice 1. A patient is taking a sulfonamide antibiotic and develops a rash that begins peeling. Which type of rash is suspected? a. Erythema multiforme b. Stevens-Johnson c. Urticaria d. Wheal and flare ANS: B The Stevens-Johnson syndrome rash typically peels in sheets. Erythema multiforme, urticaria, and wheal and flare rashes do not peel. REF: Complications 2. A child is brought to a clinic with a sudden onset of rash after taking an antibiotic for 2 days. The provider notes all over wheals with pruritis, which the parent reports seem to come and go. Which action is correct? a. Admit the child to the hospital for treatment and observation b. Prescribe an oral antihistamine and follow up in 1 to 2 days c. Reassure the parent that the rash will eventually subside d. Suggest trying cool compresses and tepid baths at home ANS: A Urticarial lesions are pruritic and often ―move.‖ The more sudden and explosive the appearance of the urticaria, the more likely that anaphylaxis may occur, so the child should be hospitalized for treatment and observation. Oral antihistamines, cool compresses, and tepid baths may be used, but the child should not be sent home. REF: Differential Diagnosis 3. Which types of medications are associated with urticarial type rashes? Select all that apply. a. ACE inhibitors b. Erythromycin c. NSAIDs d. Penicillins e. PhenothiazinesTest Bank 2 ANS: B, C, D Erythromycin, NSAIDs, and cillins are associated with urticaria. ACE inhibitors tend to cause angioedema. Phenothiazines are associated with photosensitivity. REF: Table 51-1: Skin ReactionsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 52: Dry Skin Test Bank Multiple Choice 1. A patient who has chronically dry skin who has been using emollients and moisturizers reports an uneven diamond pattern and redness on the lower legs and arms. What will the provider recommend? a. A topical antibiotic ointment b. Increasing sodium consumption c. Referral to a dermatologist d. Using antihistamines at night ANS: C This patient exhibits symptoms of eczema craquele, which is a more severe type of dry skin. Because the patient has been treated without success, referral to a dermatologist is recommended. Topical antibiotics are used only if signs of infection are present. Patients should limit sodium intake. Antihistamines are not indicated. REF: Clinical Presentation and Physical Examination/Management 2. When counseling a patient who has dry skin about ways to minimize exacerbations, what will the provider include? Select all that apply. a. Cleanse the skin frequently b. Eat soups and stews frequently c. Take tepid-water baths d. Use topical corticosteroids regularly e. Use fragrance-free detergents ANS: B, C, E Providers should recommend eating foods high in fluids, such as soups and stews. Bath water should be tepid. Patients should use products that are fragrance free. Cleansing the skin frequently increases drying. Topical corticosteroids should be used only for flare ups; too frequent use causes atrophy of the skin. REF: Patient Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. mmmm Chapter 53: Eczematous Dermatitis (Atopic Dermatitis) Test Bank Multiple Choice 1. Which is the primary symptom causing discomfort in patients with atopic dermatitis? a. Dryness b. Erythema c. Lichenification d. Pruritis ANS: D Itching is incessant and patients usually develop other signs at the site of itching. REF: Definition and Epidemiology 2. The parent of a 10-month-old child with atopic dermatitis asks what can be done to minimize the recurrence of symptoms in the child. What will the provider recommend? a. Calcineurin inhibitors b. Lubricants and emollients c. Oral diphenhydramine d. Prophylactic topical steroids ANS: B Emollients and lubricants are used long-term to reduce flare-ups. Cacineurin inhibitors are not recommended for children under 2 years. Oral diphenhydramine helps with symptoms of itching, but is not used to prevent symptoms. Corticosteroids should be used sparingly to treat symptoms and stopped once the inflammation has subsided. REF: Management 3. A child who has atopic dermatitis has recurrent secondary bacterial skin infections. What will the provider recommend to help prevent these infections? a. Bleach baths twice weekly b. Frequent bathing with soap and water c. Low-dose oral antibiotics d. Topical antibiotic ointments ANS: ATest Bank 2 Bleach baths and intranasal mupirocin have been shown to reduce bacterial superinfections of the skin. Frequent bathing with soap and water may increase flare-ups and increase the risk for superinfections. Oral and topical antibiotic prophylaxis are not recommended. REF: ComplicationsButtaro: Primary Care, A Collaborative Practice, 5th Ed. mmmm Chapter 54: Fungal Infections (Superficial) Test Bank Multiple Choice 1. Which medication will the provider prescribe as first-line therapy to treat tinea capitis? a. Oral griseofulvin b. Oral ketoconazol c. Topical clotrimazole d. Topical tolnaftate ANS: A Systemic antifungal medications are used for widespread tinea and always with infections that involve the nails or scalp. Oral ketoconazole should be avoided due to risks of hepatotoxicity and serious drug interactions. REF: Dermatophyte Infections/Management 2. When collecting a specimen to determine a diagnosis of tinea corporis, the provider will scrape which portion of the lesion? a. The active, leading border b. The area of central clearing c. The erythematous plaque d. The papular lesions ANS: A The key to a reliable KOH preparation is properly obtaining an adequate specimen by scraping the active, leading border of a lesion. The other areas do not yield a reliable specimen. REF: Dermatophyte Infections/Diagnostics 3. When evaluating scalp lesions in a patient suspected of having tinea capitis, the provider uses a Wood’s lamp and is unable to elicit fluorescence. What is the significance of this finding? a. The patient does not have tinea capitis. b. The patient is less likely to have tinea capitis. c. The patient is positive for tinea capitis. d. The patient may have tinea capitis. ANS: DTest Bank 2 Although some fungal species causing tinea capitis fluoresce with a Wood’s lamp, Trichophyton tonsurans, the most common cause or tinea capitis, does not fluoresce, so lack of fluorescence does not rule out the infection, make it less likely, or diagnose it. REF: Dermatophyte Infections/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. mmmm Chapter 55: Herpes Zoster (Shingles) Test Bank Multiple Choice 1. A patient who has had a previous herpes zoster outbreak experiences a second outbreak and asks the provider about treatment to reduce the duration and severity of symptoms. What will the provider recommend? a. Acyclovir b. Lidocaine patch c. Oral corticosteroids d. Topical corticosteroids ANS: A Acyclovir, given within 72 hours of onset of rash, has been shown to reduce the duration and severity of the rash and pain and to reduce the risk for PHN and disseminated disease. Lidocaine patches help with pain, but do not reduce the duration of the symptoms. Corticosteroids have not been shown to prevent development of PHN, but have shown modest reduction in duration and severity. REF: Management 2. An older patient experiences a herpes zoster outbreak and asks the provider if she is contagious because she is going to be around her grandchild who is too young to be immunized for varicella. What will the provider tell her? a. An antiviral medication will prevent transmission to others. b. As long as her lesions are covered, there is no risk of transmission. c. Contagion is possible until all of her lesions are crusted. d. Varicella zoster and herpes zoster are different infections. ANS: C Herpes zoster lesions contain high concentrations of virus that can be spread by contact and by air; although they are less contagious than primary infections, contagion is possible until all lesions are crusted. Antiviral medications shorten the course, but do not reduce transmission. Covering the lesions does not prevent transmission. Herpes zoster and varicella zoster are the same. REF: Pathophysiology 3. A patient has a unilateral vesicular eruption which is described as burning and stabbing in intensity. To differentiate between herpes simplex and herpes zoster, which test will the provider order?Test Bank 2 a. Polymerase chain reaction analysis b. Serum immunoglobulins c. Tzanck test d. Viral culture ANS: A The PCR is a rapid and sensitive test that can differentiate between the two. Serum Ig levels are not diagnostic. The Tzanck test identifies the presence of a herpes virus, but does not differentiate between the two types. Viral culture will differentiate, but is not rapid. REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. mmmm Chapter 56: Hidradenitis Suppurativa (Acne Inversa) Test Bank Multiple Choice 1. Which medications may be used as part of the treatment for a patient with hidradenitis suppurativa? Select all that apply. a. Chemotherapy b. Erythromycin c. Infliximab d. Isotretinoin e. Prednisone ANS: B, C, D, E Hidradenitis suppurativa is not malignant and chemotherapy is not used. Erythromycin, infliximab, isotretinoin, and prednisone are all used. REF: Hidradenitis Suppurativa/Management 2. A female patient is diagnosed with hidradenitis suppurativa and has multiple areas of swelling, pain, and erythema, along with several abscesses in the right femoral area. When counseling the patient about this disorder, the practitioner will include which information? a. Antibiotic therapy is effective in clearing up the lesions. b. It is often progressive with relapses and permanent scarring. c. The condition is precipitated by depilatories and deodorants. d. The lesions are infective and the disease may be transmitted to others. ANS: B Although lesions may be treated with antibiotics, other medications, and drainage, the disease is often progressive, with relapses and permanent scarring. Deodorants and depilatories are not implicated as a cause. The disease is not transmitted to others, although the organisms may cause other infections in other people. REF: Hidradenitis Suppurativa/Management/Patient EducationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 57: Hyperhidrosis Test Bank Multiple Choice 1. A patient is newly diagnosed with hyperhidrosis with excessive sweating on the palms and soles. What will the provider recommend to treat this condition? a. Aluminum chloride hexahydrate b. Liposuction of sweat glands c. Oral anticholinergic agents d. Thoracic endoscopic surgery ANS: A Topical aluminum chloride hexahydrate is used initially for excessive perspiration on hands, feet, and in the axillae. Liposuction is performed on axillary glands. Oral anticholinergics may be used, but the initial treatment is the topical preparation. Thoracic endoscopic surgery may be used if other treatments fail. REF: Management 2. A patient has excessive sweating of the palms, soles, and axillae. The provider understands that this presentation is often due to which cause? a. Anxiety b. Hormones c. Hypoglycemia d. Medications ANS: A Localized excessive sweating is usually due to anxiety, heat, or is idiopathic, while more generalized excessive sweating may be due to underlying conditions. REF: Clinical Presentation 3. A patient reports generalized excessive sweating and states that night sweats are present. Which diagnostic test is a priority for this patient to determine the underlying cause? a. Blood pressure evaluation b. Fasting blood glucose c. Purified protein derivative test d. Thyroid function tests ANS: CTest Bank 2 When night sweats are present, a PPD is done to exclude tuberculosis. Blood pressure evaluation is performed if pheochromocytoma is suspected. Fasting blood glucose and thyroid testing will be performed to exclude thyroid disease and diabetes. Since night sweats are common with TB, this test has priority. REF: Physical Examination/Diagnostics and Differential DiagnosisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 58: Intertrigo Test Bank Multiple Choice 1. A patient with intertrigo shows no improvement and persistent redness after treatment with drying agents and antifungal medications. The patient reports an onset of odor associated with a low-grade fever. What will the provider do next to manage this condition? a. Culture the lesions to determine the cause b. Evaluate the patient for HIV infection c. Order topical nystatin cream d. Prescribe a cephalosporin antibiotic ANS: A This patient has symptoms of a secondary bacterial infection. The lesions should be cultured and the results used to determine the appropriate antibiotic. Patients with recurrent candida infections should be evaluated for underlying HIV infection, diabetes, and other immunocompromised states. Topical nystatin cream is used for candida infection and these symptoms are consistent with bacterial infection. Antibiotics should be chosen based on culture results. REF: Management 2. When recommending ongoing treatment for a patient who has recurrent intertrigo, what will the provider suggest? Select all that apply. a. Aluminum sulfate solution b. Burow’s solution compresses c. Cornstarch application d. Nystatin cream e. Topical steroid cream ANS: A, B Aluminum sulfate solution and other drying agents are recommended and Burow’s solution compresses may be soothing. Cornstarch is ineffective and may result in fungal growth. Nystatin cream is used only for candida intertrigo. Topical steroids may promote infection. REF: Management 3. An overweight patient has intertrigo, with recurrent fungal infections. In addition to medication therapy, what will the provider recommend to treat the condition?Test Bank 2 Select all that apply. a. Apply moisturizer to affected areas b. Expose areas to light and air c. Use a hand-held dryer to dry the area d. Use powder containing cornstarch e. Wear natural-fiber clothing ANS: B, C, E Affected areas should be kept clean and dry to reduce the incidence of recurrence. Exposing skin to light and air several times daily, using a hair dryer on low setting, and wearing natural-fiber clothing are all recommended. Applying moisturizer and using cornstarch are not recommended. REF: Patient and Family Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 59: Nail Disorders Test Bank Multiple Choice 1. A patient with recurrent herpetic whitlow is counseled about management of symptoms and prevention of complications. What will be included in this teaching? Select all that apply. a. Begin antiviral medications within 3 days of onset of symptoms b. Contact the provider if symptoms persist longer than 3 weeks c. Coolcompresses may help with comfort and decrease erythema d. Keep hands away from the mouth and eyes to prevent inoculation e. Wear gloves when preparing foods to prevent spread to others ANS: B, C, D Patients with herpetic whitlow should be seen by a physician if symptoms are recalcitrant to treatment after 3 weeks. Cool compresses may help with symptomatic relief. Patients should avoid touching the mouth and eyes to prevent spread of lesions to these tissues. Antiviral medications should be given within 48 hours of onset of symptoms to be effective. Wearing gloves during food preparation is not necessary. REF: Herpetic Whitlow/Management/Education and Health Promotion 2. A patient is diagnosed with herpetic whitlow and in a follow-up evaluation, is noted to have paronychial inflammation of the tendon sheath in one finger. What is a priority treatment for this patient? a. Begin therapy with an oral antiviral medication b. Obtain a consult for incision and drainage of the lesion c. Ordera creatinine clearance test to evaluate renal function d. Refer the patient to the emergency department ANS: D When paronychial infection of the tendon sheath is suspected in patients with herpetic whitlow, they should be immediately referred to the emergency department for a surgical referral. Oral antiviral medications are given for severe cases and recurrences, but the emergent situation is a priority. Incision and drainage may lead to superinfection of longer healing. Creatinine clearance is ordered when beginning oral antiviral therapy. REF: Herpetic Whitlow/ManagementTest Bank 2 3. A female patient who works with caustic chemicals has developed acute paronychia. What will he provider include when teaching this patient about her condition? Select all that apply. a. Analgesics may be necessary for comfort b. Apply clear nail polish to protect her nails c. Avoid trimming the nails until the infection clears d. Use protective gloves while working e. Wear waterproof gloves when washing dishes ANS: A, D, E Patients with paronychia may require analgesics for comfort. They should be instructed to wear protective gloves while working, if the condition is work-related and to wear waterproof gloves while washing dishes. Nail polish should be avoided and nails should be kept trimmed and clean REF: Paronychia/Management/Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 60: Pigmentation Changes (Vitiligo) Test Bank Multiple Choice 1. A patient with well-localized vitiligo is referred to a dermatologist for treatment. What will the initial treatment be? a. Chemical depigmentation with mequinol b. Narrow-band ultraviolet B light therapy c. Psoralens plus ultraviolet A light d. Twice-daily application of a mid-potency steroid cream ANS: D The initial treatment for vitiligo is twice-daily mid-potency steroids. UVA and UVB therapy with psoralens may be used if this isn’t effective and must be performed by a qualified specialist. Patients with widespread areas of vitiligo may be treated with depigmentation therapy. REF: Management 2. A parent reports the appearance of areas of depigmented skin on a child which has spread rapidly. The provider notes asymmetrically patterned tri-colored, macules in a dermatomal distribution. What type of vitiligo does the provider suspect? a. Inflammatory vitiligo b. Segmented vitiligo c. Type A vitiligo d. Vitiligo with poliosis ANS: B Segmented, or dermatomal vitiligo, spreads rapidly, is usually asymmetrical, and tends to occur in children. Inflammatory vitiligo occurs after inflammation of the skin. Type A vitiligo is nondermatomal and is generally symmetric. Poliosis occurs when well-defined areas of white hair occur. REF: Clinical Presentation 3. A patient who is diagnosed with vitiligo asks the provider what can be done to minimize the contrast between depigmented and normal skin. What will the provider recommend? a. Applying a cosmetic cover-up or tanning cream b. Lightening the dark skin areas with hydrogen peroxide c. Tanning for limited periods in a tanning boothTest Bank 2 d. Waiting for all skin to become depigmented ANS: A Cosmetic cover-ups or tanning creams are useful to help darken affected areas. Hydrogen peroxide is not recommended. Tanning is contraindicated; excessive sunburn can stimulate depigmentation. Waiting for widespread depigmentation is unpredictable. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 61: Pruritus Test Bank Multiple Choice 1. A patient has pruritis related to use of fabric softeners in clothing and reports all-over itching. A physical examination reveals no areas of inflammation. Besides stopping the use of this product, what is an initial intervention to stop the pruritis? a. Application of capsaicin b. Cooling the skin c. Topical antihistamines d. Topical corticosteroids ANS: B Cooling of the skin by wearing light clothing or using a fan can help stop pruritis and should be initiated first. Capsaicin is used for localized pruritis. Topical antihistamines are sensitizers and should be discouraged. Topical corticosteroids are reserved for cases of cutaneous inflammation. REF: Management 2. A patient undergoing renal dialysis has extensive pruritis. Which medication will the provider order? a. Cholestyramine (Questran) b. Cyproheptadine (Periactin) c. Doxepin (Sinequan) d. Gabapentin (Neurontin) ANS: D Gabapentin is useful for patients who experience pruritis as a result of dialysis. Cholestyramine is used for pruritis caused by cholestasis. Cyproheptadine is used for patient with pruritis resulting from polycythemia vera. Doxepin is used for its anxiolytic effects. REF: Systemic Therapy 3. A patient complains of persistent pruritis of the extremities. A history is negative for medical and psychiatric causes and the patient has not had significant exposures. The physical examination of the affected skin is negative, except for marks made by scratching. What will the provider order to evaluate the cause of this itching? Select all that apply.Test Bank 2 a. A skin biopsy specimen b. Blood urea nitrogen and serum creatinine c. Complete blood count with differential d. Referral for psychiatric evaluation e. Thyroid panel and blood glucose ANS: B, C, E Initial laboratory tests should include a CBC with differential, BUN and creatinine, a thyroid panel, and a blood glucose. Skin biopsy may be done if lesions are present. If other causes are ruled out, a psychiatric evaluation may be ordered. REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 62: Psoriasis Test Bank Multiple Choice 1. A child has plaques on the extensor surfaces of both elbows and on the face with minimal scaling and pruritis. What is the likely cause of these lesions? a. Atopic dermatitis b. Guttate psoriasis c. Psoriasis d. Seborrhea ANS: C Children with psoriasis often have lesions on the face and have less scaling than adults. Psoriasis tends to present on extensor surfaces, while atopic dermatitis occurs on flexor surfaces. Guttate psoriasis appears as teardrop-shaped lesions that appear on the trunk and spread to the extremities and are occasionally seen after streptococcal infections in adolescents. Seborrhea usually occurs on the scalp. REF: Definition and Epidemiology/Differential Diagnosis 2. A patient with psoriasis develops lesions on the intertriginous areas of the skin. Which treatment is recommended? a. High-potency topical steroids b. Oral corticosteroid injections c. Topical steroids with vitamin D d. Topical, low-potency steroids ANS: D Patients with intertriginous psoriasis should be treated with low-potency topical steroids. Highpotency steroids usually produce maximum benefit in 2 to 3 weeks and research suggests combining high-potency steroids with vitamin D analog is best. Oral corticosteroids are used for recalcitrant symptoms. REF: Management/Topical Therapy 3. A patient with severe, recalcitrant psoriasis has tried topical medications, intralesional steroid injections, and phototherapy with ultraviolet B light without consistent improvement in symptoms. What is the next step in treating this patient? a. Cyclosporine b. EtanerceptTest Bank 2 c. Methotrexate d. Oral retinoids ANS: C Methotrexate has shown good efficacy in treating recalcitrant psoriasis. Cyclosporine and oral retinoids are effective, but have serious side effects. Etanercept and other biologic agents are effective but expensive and should be tried after all other treatments have failed. REF: Management/Systemic Medications/Biologic AgentsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 63:Purpura Test Bank Multiple Choice 1. A patient has a purpural rash with flat, non-palpable lesions. Which laboratory tests will be most helpful in the initial diagnosis? a. Blood urea nitrogen and liver function studies b. Complete blood count with platelets c. Erythrocyte sedimentation rate or C-reactive protein d. Prothrombin time, partial thromboplastin time, and international normalized ratio ANS: B The initial diagnostic workup should include a CBC and platelet count and is most helpful in the initial diagnosis. BUN and LFTs are used to exclude organ disease and may be performed as part of the differential diagnosis. The ESR and CRP are used if the lesions are thought to be related to an inflammatory cause. The PT, PTT, and INR are used to determine the presence of coagulopathies. REF: Diagnostics 2. A pediatric patient has immune thrombocytopenic purpura and has a platelet count of 60,000/mm3. What is the recommended treatment based on this laboratory value? a. Close observation b. High-dose steroids c. Intravenous immunoglobulin d. Possible splenectomy ANS: A Immune thrombocytopenic purpura (ITP) may have mild to severe symptoms. Treatment is usually reserved for those with a platelet count less than 50,000/mm3 and may include steroids, immunoglobulin, and possible splenectomy. This child has levels high enough to warrant observation without treatment. REF: Differential Diagnosis 3. A patient presents with a purpural rash. The provider notes localized swelling and palpable lesion. What underlying condition may be the cause of this rash? a. A bleeding disorder b. A medication hypersensitivity c. A vasculitis disorderTest Bank 2 d. An infectious disease ANS: C Inflammatory purpura is most often palpable and is associated with the vasculitides. Noninflammatory purpura may be caused by infectious disease, medication hypersensitivity, and bleeding disorders. REF: Differential DiagnosisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 64: Scabies Test Bank Multiple Choice 1. An adult patient has greasy, scaling patches on the forehead and eyebrows suggestive of seborrheic dermatitis. What is included in assessment and management of this condition? Select all that apply. a. Begin first-line treatment with a topical antifungal medication b. Evaluate the scalp for dry, flaky scales and treat with selenium sulfide shampoo c. Teach the patient that proper treatment is curative in most instances d. Topical antibacterial medications may be used to prevent Malassezia proliferation e. Use topical steroids for several weeks to prevent recurrence of symptoms ANS: A, B First-line therapy may include topical antifungals or corticosteroids. Adults with symptoms on the face or eyebrows are likely to have scalp lesions, since this is usually a ―top-down‖ disorder. The condition is chronic and recurrent. Antibacterial medications are used for secondary bacterial infections but do not treat Malazessia, which is a fungus. Topical steroids should be used on a short-term basis. REF: Management/Patient and Family Education 2. The provider is prescribing 5% permethrin cream for an adolescent patient who has scabies. What will the provider include in education for this patient? a. All household contacts will betreated only if symptomatic. b. Itching 2 weeks after treatment indicates treatment failure. c. Stuffed animals and pillows should be placed in plastic bags for 1 week. d. The adolescent’s school friends should be treated. ANS: C Bedding and clothing of persons with scabies should be washed in hot water and dried on hot dryer settings. Items that cannot be washed should be put in plastic bags for 1 week. All household contacts should be treated. Itching may persist as a result of the secondary dermatitis for up to 2 weeks and does not represent treatment failure. Casual contacts do not require treatment. REF: Management/Patient and Family Education 3. A patient has a pruritic eczematous dermatitis which has been present for one week and reports similar symptoms in other family members. What will the practitioner look for to help determine a diagnosis of scabies?Test Bank 2 a. Bullous lesions on the soles of the feet and palms of the hands b. Intra-epidermal burrows on the interdigital spaces of the hands c. Nits and small bugs along the scalp line at the back of the neck d. Pustular lesions in clusters onthe trunk and extremities ANS: B The scabies mite typically burrows no deeper than the stratus corneum and burrows may be found in the interdigital spaces of the hands, among other places. Bullous lesions may occur with impetigo. Nits and small bugs are characteristic findings with pediculosis. Pustular lesions represent superficial skin infections. REF: Clinical Presentation and Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 65: Seborrheic Dermatitis Test Bank Multiple Choice 1. An adult patient has greasy, scaling patches on the forehead and eyebrows suggestive of seborrheic dermatitis. What is included in assessment and management of this condition? Select all that apply. a. Begin first-line treatment with a topical antifungal medication b. Evaluate the scalp for dry, flaky scales and treat with selenium sulfide shampoo c. Teach the patient that proper treatment is curative in most instances d. Topical antibacterial medications may be used to prevent Malassezia proliferation e. Use topical steroids for several weeks to prevent recurrence of symptoms ANS: A, B First-line therapy may include topical antifungals or corticosteroids. Adults with symptoms on the face or eyebrows are likely to have scalp lesions, since this is usually a ―top-down‖ disorder. The condition is chronic and recurrent. Antibacterial medications are used for secondary bacterial infections but do not treat Malazessia, which is a fungus. Topical steroids should be used on a short-term basis. REF: Management/Patient and Family Education 2. A patient with chronic seborrheic dermatitis reports having difficulty remembering to use the twice daily ketoconazole cream prescribed by the provider. What will the provider order for this patient? a. Burow’s solution soaks once daily b. Oral corticosteroids c. Oral itraconazole (Sporanox) d. Selenium sulfide shampoo 2.5% as a daily rinse ANS: C Itraconazole is effective for moderate to severe symptoms and is an alternative for those who do not wish to use topical treatment. Burow’s solution and selenium shampoo rinses are not indicated. Oral corticosteroids are usually not given. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 66: Stasis Dermatitis Test Bank Multiple Choice 1. Which treatment is most important in long-term management of stasis dermatitis? a. ―Active‖ dressing application b. Compression therapy c. Massage therapy d. Systemic antibiotics ANS: B Compression therapy is considered the gold standard of treatment for stasis dermatitis. ―Active‖ dressings are used when ulcerations occur to help with wound healing. Massage therapy is not recommended. Systemic antibiotics are used only when secondary infections occur. REF: Management 2. A patient who has stasis dermatitis is instructed to apply an emollient to the skin around the ankles. What is the reason for this recommendation? a. To encourage formulation of granulation tissue b. To maintain optimum skin integrity c. To minimize the risk of allergic contact dermatitis d. To prevent itching and inflammation ANS: B Emollients are used to maintain skin integrity. When ulcerations form, topically applied growth factor is used to help with granulation tissue formation. Using plain petrolatum as an emollient, rather than a product with potentially irritating chemicals, will help prevent allergic contact dermatitis. Corticosteroids are used for itching and inflammation. REF: Management 3. Which are elements of patient education when counseling a client who has stasis dermatitis about preventing complications associated with this disease? Select all that apply. a. Applying emollients daily b. Keeping legs elevated when seated c. Minimizing exercise and ambulation d. Reducing fluid intakeTest Bank 2 e. Weight reduction ANS: A, B, E Patients should be encouraged to apply emollients daily, to keep legs elevated when seated as much as possible, and to lose weight if needed. Exercise and ambulation should be encouraged. Reducing fluids is not recommended because this will reduce circulating blood volume. REF: Patient and Family EducationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 67: Urticaria Test Bank Multiple Choice 1. A patient describes a wheal and flare type rash that recurs frequently with hives that appear and then fade within an hour. The provider notes that the patient demonstrates a wheal and flare reaction when the skin is stroked with a pen. What will the provider ask the patient to help determine the cause of this rash? a. If the patient takes any medications, such as NSAIDs regularly b. If there is a family history of thyroid autoimmunity disease c. Whether the patient is experiencing gastrointestinal discomfort d. Whether the patient is exposed to cold or water prior to the rash ANS: D Urticaria caused by physical triggers, such as cold or water, tends to develop quickly and then fade within an hour and will also exhibit dermatographism, which is a wheal and flare reaction to physical stimuli. The other factors tend to cause more typical urticaria that develops more slowly and lasts longer. REF: Definition and Epidemiology 2. A patient with chronic urticaria is taking a high dose non-sedating H1 blocker medication but reports minimal relief from itching. What will the provider prescribe to help alleviate this symptom? a. A corticosteroid b. A leukotriene inhibitor c. A sedating antihistamine d. An H2 blocker ANS: D For urticaria refractory to H1 blockade, evidence exists for clinical benefit when an H2 blocker is added. Corticosteroids are useful for acute urticaria. Leukotriene inhibitors may be useful in some, but clinical trials are inconclusive. Addition of a sedating antihistamine at bedtime will help patients sleep, but does not add much to symptom control. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 68: Warts Test Bank Multiple Choice 1. A pregnant woman has a history of human papillomavirus (HPV) and asks what she should do to prevent spread of this disease to her newborn. What will the provider recommend? a. Administration of the HPV vaccine b. Elective caesarean section c. No precautions are necessary d. Referral for cryotherapy ANS: B Infants born to mothers with HPV infection may contract the virus during passage through the birth canal, so elective caesarean section may be performed to prevent this exposure. HPV vaccine is not given once infection has occurred. Cryotherapy is not indicated. REF: Pathophysiology/Management 2. An adolescent patient has several warts on one hand. Which action by the provider is indicated? a. Evaluate the patient’s HPV immunization status b. Reassure the patient that these lesions will regress spontaneously c. Remind the patient not to touch the genitals to prevent self-inoculation d. Treat the patient with either chemical agents or cryotherapy ANS: B Most warts are benign and will regress spontaneously over time. Warts on the hands and feet do not have an affinity for anogenital areas, so HPV immunization is not considered when evaluating these warts and patients do not have to be taught to avoid touching these areas. Chemical agents or cryotherapy may be used for wart that are painful or for cosmetic reasons. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 69: Wound Management Test Bank Multiple Choice 1. A patient has a pressure ulcer that has been treated with topical medications. During a follow-up visit, the provider notes an area of red bumps in the lesion. What does this indicate? a. Healing tissue b. Poor perfusion c. Secondary infection d. Tunneling lesions ANS: A Wounds that are healing of have the potential to heel will demonstrate pink or red tissue and the absence of exudate, infection, or debris and will have bumpy granulation tissue. Perfusion is assessed by pulse assessment and localized capillary refill. Secondary infection is characterized by exudate and cellular debris. Tunneling is a secondary wound. REF: Physical Examination 2. A patient has an ulcer on one lower leg just above the medial malleolus. The provider notes irregular wound edges with granulation tissue and moderate exudate, with ankle edema in that leg. What is the initial treatment to help treat this wound? a. Compression therapy b. Hyperbaric oxygen therapy c. Revascularization procedures d. Skin grafting ANS: A This patient has symptoms consistent with venous ulcers, which are characterized by irregular borders and granulation tissue. Compression therapy is the initial treatment of choice to reduce edema and promote venous return. Hyperbaric oxygen therapy, revascularization procedures, and skin grafting are generally used to treat arterial ulcers. REF: Ulcers: Venous and Arterial/Management 3. A patient with a wound containing necrotic tissue requires debridement. The practitioner notes an area of erythema and exudate in the wound. Which type of debridement will most likely be used?Test Bank 2 a. Autolytic debridement b. Biologic debridement c. Chemical debridement d. Mechanical debridement ANS: D Mechanical debridement may be performed using a syringe with an 18-gauge needle to remove hyperkeratotic or necrotic tissue. Autolytic and chemical debridement methods require dressings that retain moisture and are contraindicated in the presence of infection. Biologic debridement uses maggots and is not widely used in the U.S. REF: DebridementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 70: Evaluation of the Eyes Test Bank Multiple Choice 1. During an eye examination, the provider notes a red light reflex in one eye but not the other. What is the significance of this finding? a. Normal physiologic variant b. Ocular disease requiring referral c. Potential infection in the ―red‖ eye d. Potential vision loss in one eye ANS: B The red reflex should be elicited in normal eyes. Any asymmetry or opacity suggests ocular disease, potentially retinoblastoma, and should be evaluated immediately. REF: Posterior Segment 2. A patient comes to clinic with diffuse erythema in one eye without pain or history of trauma. The examination reveals a deep red, confluent hemorrhage in the conjunctiva of that eye. What is the most likely treatment for this condition? a. Order lubricating drops or ointments b. Prescribe ophthalmic antibiotic drops c. Reassure the patient that this will resolve d. Refer to an ophthalmologist ANS: C Most subconjunctival hemorrhage, occurring with trauma or Valsalva maneuvers, will selfresolve and are benign. Lubricating drops are used for chemosis. Antibiotic eye drops are not indicated. Referral is not indicated. REF: Anterior Segment 3. A provider performs an eye examination during a health maintenance visit and notes a difference of 0.5 mm in size between the patient’s pupils. What does this finding indicate? a. A relative afferent pupillary defect b. Indication of a difference in intraocular pressure c. Likely underlying neurological abnormality d. Probable benign, physiologic anisocoriaTest Bank 2 ANS: D A difference in diameter of less than 1 mm is usually benign. Afferent pupillary defects are paradoxical dilations of pupils in response to light. This does not indicate differences in intraocular pressure. A difference of more than 1 mm is more likely to represent an underlying neurological abnormality. REF: Pupil ResponseButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 71: Cataracts Test Bank Multiple Choice 1. A primary care provider may suspect cataract formation in a patient with which finding? a. Asymmetric red reflex b. Corneal opacification c. Excessive tearing d. Injection of conjunctiva ANS: A An asymmetric red reflex may be a finding in a patient with cataracts. Corneal opacification, excessive tearing, and corneal injection are not symptoms of cataracts. REF: Physical Examination 2. Which are risk factors for development of cataracts? Select all that apply. a. Advancing age b. Cholesterol c. Conjunctivitis d. Smoking e. Ultraviolet light ANS: A, D, E Most older adults will develop cataracts. Smoking and UV light exposure hasten the development of cataracts. Cholesterol and conjunctivitis are not risk factors. REF: PathophysiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 72: Blepharitis, Hordeolum, and Chalazion Test Bank Multiple Choice 1. A child has a localized nodule on one eyelid which is warm, tender, and erythematous. On examination, the provider notes clear conjunctivae and no discharge. What is the recommended treatment? a. Referral to an ophthalmologist b. Surgical incision and drainage c. Systemic antibiotics d. Warm compresses and massage of the lesion ANS: D This child has a hordeolum, which is generally self-limited and usually spontaneously improves with conservative treatment. Warm compresses and massage of the lesion are recommended. Referral is not necessary unless a secondary infection occurs. Surgical intervention is not indicated. Systemic antibiotics are used to treat secondary cellulitis. REF: Management 2. A patient has a gradually enlarging nodule on one upper eyelid and reports that the lesion is painful. On examination, the lesion appears warm and erythematous. The provider knows that this is likely to be which type of lesion? a. Blepharitis b. Chalazion c. Hordeolum d. Meibomian ANS: C Although hordeolum and chalazion lesions both present as gradually enlarging nodules, a hordeolum is usually painful, while a chalazion generally is not. Blepharitis refers to generalized inflammation of the eyelids. Meibomian is a type of gland near the eye. REF: Clinical Presentation 3. A patient reports has been using artificial tears for comfort because of burning and itching in both eyes, but reports worsening symptoms. The provider notes redness and discharge along the eyelid margins with clear conjunctivae. What is the recommended treatment? a. Antibiotic solution dropsfour times dailyTest Bank 2 b. Compresses, lid scrubs, and antibiotic ointment c. Oralantibiotics given prophylactically for several months d. Reassurance that this is a self-limiting condition ANS: B This patient has symptoms of blepharitis without conjunctivitis. Initial treatment involves lid hygiene and antibiotic ointment may be applied after lid scrubs. Antibiotic solution is used if conjunctivitis is present. Oral antibiotics are used for severe cases. This disorder is generally chronic. REF: Clinical Presentation/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 73: Conjunctivitis Test Bank Multiple Choice 1. A patient who has a cold develops conjunctivitis. The provider notes erythema of one eye with profuse, watery discharge and enlarged anterior cervical lymph nodes, along with a fever. Which treatment is indicated? a. Antihistamine-vasoconstrictor drops b. Artificial tears and cool compresses c. Topical antibiotic eye drops d. Topical corticosteroid drops ANS: B Viral conjunctivitis accompanies URI and is generally self-limited, lasting 5 to 14 days. Symptomatic treatment is recommended. Antihistamine-vasoconstrictor drops are used for allergic conjunctivitis. Topical antibiotic drops are sometimes used for bacterial conjunctivitis. Topical corticosteroid drops are used for severe inflammation. REF: Management/Viral Conjunctivitis 2. A patient reports bilateral reports burning and itching eyes for several days. The provider notes a boggy appearance to the conjunctivae, along with clear, watery discharge. The patient’s eyelids are thickened and discolored. There are no other symptoms. Which type of conjunctivitis is most likely? a. Allergic b. Bacterial c. Chemical d. Viral ANS: A Allergic conjunctivitis generally presents simultaneously in both eyes with itching as a predominant feature. Discharge is generally clear or stringy and white and the patient will have lid discoloration, thickening, and erythema. Bacterial conjunctivitis is characterized by acute inflammation of the conjunctivae along with purulent discharge. Chemical conjunctivitis will not have purulent discharge. Viral conjunctivitis is usually in association with a URI. REF: Clinical Presentation/Acute Allergic ConjunctivitisTest Bank 2 3. A patient with allergic conjunctivitis who has been using a topical antihistaminevasoconstrictor medication reports worsening symptoms. What is the provider’s next step in managing this patient’s symptoms? a. Consider prescribing a topical mast cell stabilizer b. Determine the duration of treatment with this medication c. Prescribe a non-sedating oral antihistamine d. Refer the patient to an ophthalmologist for further care ANS: B Antibiotic-vasoconstrictor agents can have a rebound effect with worsening symptoms if used longer than 3 to 7 days, so the provider should determine whether this is the cause. Topical mast cell stabilizers are useful as prophylaxis for recurrent or persistent allergic conjunctivitis and results do not occur for several weeks. Oral antihistamines may be the next step if it is determined that the cause of worsening symptoms is related to the allergy. It is not necessary to refer to ophthalmology at this time. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 74: Corneal Surface Defects and Ocular Surface Foreign Bodies Test Bank Multiple Choice 1. Which patients should be referred immediately to an ophthalmologist after eye injury and initial treatment? Select all that apply. a. A patient who was sprayed by lawn chemicals b. A patient who works in a metal fabrication shop c. A patient with a corneal abrasion d. A patient with a full-thickness corneal laceration e. A patient with irritation secondary to wood dust ANS: A, B, D Patients with chemical eye injuries, any with possible metallic foreign bodies, and those with full-thickness corneal lacerations must have immediate referral. Corneal abrasions and irritation from wood dust may be managed by primary care providers. REF: Management/Box 74-2: Indications for Immediate Ophthalmology Referral 2. A patient who works in a furniture manufacturing shop reports a sudden onset of severe eye pain while sanding a piece of wood and now has copious tearing, redness, and light sensitivity in the affected eye. On examination, the conjunctiva appears injected, but no foreign body is visualized. What is the practitioner’s next step? a. Administration of antibiotic eye drops b. Application of topical fluorescein dye c. Instillation of cyclopegic eye drops d. Irrigation of the eye with normal saline ANS: B The practitioner must determine if there is a corneal abrasion and will instill fluorescein dye in order to examine the cornea under a Wood’s lamp. Antibiotic eye drops are not indicated as initial treatment. Cyclopegic drops are used occasionally for pain control, but should be used with caution. Irrigation of the eye is indicated for chemical burns. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 75: Dry Eye Syndrome Test Bank Multiple Choice 1. A patient has evaporative dry eye syndrome with eyelid inflammation. What are some pharmacologic and non-pharmacologic measures the provider can recommend? Select all that apply. a. Apply over-the-counter artificial tears as needed b. Avoid direct exposure to air conditioning c. Topical steroid eye drops as a maintenance medication d. Use non-tearing baby shampoo to gently scrub the eyelids e. Use tetrahydrozoline drops for discomfort ANS: A, B, D Patients with dry eye are encouraged to use OTC artificial tears to help moisten the eyes. Avoiding exposure to fans, air conditioning, and wind is recommended. Non-tearing baby shampoo may be used to cleanse the lids in patients with eyelid inflammation. Topical steroid eye drops should be used sparingly and for short periods of time. Tetrahydozoline drops constrict blood vessels and may dry eyes further. REF: Management 2. A patient has chronically dry eyes, sometimes with a foreign body sensation, burning, and itching. A Schirmer test is abnormal. What is the suspected cause of this patient’s symptoms based on this test finding? a. Aqueous-deficiency b. Corneal abrasion c. Evaporative disorder d. Pooreyelid closure ANS: A An abnormal Schirmer test, which assesses aqueous production, indicates aqueous-deficient dry eye. A corneal abrasion usually causes excessive tearing. An evaporative disorder is determined by an evaluation of tear breakup time. Poor eyelid closure causes increased corneal exposure and increased evaporation of tears. REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 76: Nasolacrimal Duct Obstruction and Dacryocystitis Test Bank Multiple Choice 1. A patient has dacryocystitis. The provider notes a painful lacrimal sac abscess that appears to be coming to a head. Which treatment will be useful initially? a. Eyelid scrubs with baby shampoo b. Incision and drainage c. Lacrimal bypass surgery d. Topical antibiotic ointment ANS: B When an abscess is present and coming to a head, incision and drainage may be useful. Definitive treatment with lacrimal bypass surgery will be performed once the acute episode has resolved. Eyelid scrubs and topical ointments are not effective. REF: Management 2. An adult patient with a history of recurrent sinusitis and allergic rhinitis reports chronic tearing in one eye, ocular discharge, and eyelid crusting. The provider suspects nasolacrimal duct obstruction. Which initial treatment will the provider recommend? a. Antibiotic eye drops b. Nasolacrimal duct probing c. Systemic antibiotics d. Warm compresses ANS: D This is most likely acquired nasolacrimal duct obstruction. Initial treatment should include warm compresses. Antibiotics are only used if infection is present. Nasolacrimal duct probing is not useful for acquired conditions; definitive treatment usually requires surgery. REF: Clinical Presentation/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 77: Preseptal and Orbital Cellulitis Test Bank Multiple Choice 1. A patient has eyelid swelling with erythema and warmth and reports pain with eye movement. Which diagnostic tests will be performed to confirm a diagnosis of orbital cellulitis? Select all that apply. a. Blood cultures b. Complete blood count c. CT scan of orbits d. Lumbar puncture e. Visual acuity testing ANS: B, C A complete blood count will help distinguish infectious from non-infectious orbital cellulitis. A CT scan or the orbits is necessary to confirm the diagnosis. Blood cultures do not confirm the diagnosis of orbital cellulitis, but may be used to evaluate whether septicemia is occurring. Lumbar puncture is indicated if meningitis is suspected. Visual acuity testing may be used to monitor recovery. REF: Diagnostics 2. Which is the most common cause of orbital cellulitis in all age groups? a. Bacteremic spread from remote infections b. Inoculation from local trauma or bug bites c. Local spread from the ethmoid sinus d. Paranasal sinus inoculation ANS: C Because the membrane separating the ethmoid sinus from the orbit is literally paper-thin, this is the most common source of orbital infection in all age groups. Bacteremic spread, inoculation from localized trauma, and paranasal sinus spread all may occur, but are less common. REF: Pathophysiology 3. A child has unilateral eyelid edema, warmth and erythema and does not exhibit pain with ocular movement. Which is most likely true about this child’s infection? a. Decreased visual acuity may occurTest Bank 2 b. Increased intraocular pressure will be present c. Optic nerve compromise is a complication d. The eye is typically spared without conjunctivitis ANS: D This child has symptoms of preseptal cellulitis in which the eye is typically spared. The other findings are consistent with orbital cellulitis. REF: Clinical Presentation and Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 78: Pinguecula and Pterygium Test Bank Multiple Choice 1. A patient has an elevated, yellowish-white lesion adjacent to the cornea at the 3 o’clock position of the right eye. The provider notes pinkish inflammation with dilated blood vessels surrounding the lesion. What will the provider tell the patient about this lesion? a. Artificial tear drops are contraindicated b. Spontaneous bleeding is likely c. UVB eye protection is especially important d. Visine may be used for symptomatic relief ANS: C This patient has a pinguecula which has become inflamed. Wide-brimmed hats and sunglasses with UVB protection should be advised since UVB light will make this worse. Artificial tear drops are recommended to reduce irritation. These types of lesions typically do not bleed spontaneously. Visine is contraindicated because chronic vasoconstriction may lead to rebound inflammation. REF: Clinical Presentation/Management 2. A patient who has an inflamed pterygia lesion has been using loteprednol topical steroid drops for 7 days. The patient shows no improvement in symptoms. What is the next course of action? a. Consult with an ophthalmologist b. Continue the medication for 7 more days c. Prescribe a systemic corticosteroid d. Refer the patient to the emergency department ANS: A Topical steroid medications are used to treat pterygia, but should not be used longer than 7 days without ophthalmic consultation. Systemic corticosteroids are not indicated and an emergent referral is not necessary. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 79: Traumatic Ocular Disorders Test Bank Multiple Choice 1. A child sustains an ocular injury in which a shard of glass from a bottle penetrated into the eye wall. The emergency department provider notes that the shard has remained in the eye. Which best describes this type of injury? a. Intraocular foreign body b. Penetrating eye injury c. Perforating eye injury d. Ruptured globe injury ANS: A When a portion of the insulting object enters and remains in the eye, the injury is correctly referred to as an intraocular foreign body. A penetrating injury occurs when something penetrates through the eye wall without an exit wound. A perforating injury occurs when the object has both an entry and an exit wound. A ruptured globe injury occurs when blunt force causes the eye wall to rupture. REF: Definition 2. A patient suffers a penetrating injury to one eye caused by scissors. The provider notes a single laceration away from the iris that involves the anterior but not the posterior segment. What is the prognosis for this injury? a. Because the posterior segment is not involved, the prognosis is good b. Blindness is likely with this type of eye injury c. Massive hemorrhage and loss of intraocular contents is likely d. Retinal detachment is almost certain to occur ANS: A Mechanical energy imparted from sharp objects generally results in lacerations, with disruption that is more localized. The prognosis is better if the posterior segment is not involved. The other complications are more common with globe ruptures. REF: Mechanical Injuries 3. Which is an important protective precaution in a metal fabrication workshop? a. 2 mm polycarbonate safety glasses b. Eyewash stations c. Glasses with UVB protectionTest Bank 2 d. Polycarbonate goggles ANS: D Polycarbonate goggles, which have better side protection, will protect from foreign bodies that can reach around other lenses and should be used in very high risk activities, such as hammering metal on metal or grinding. 2 mm polycarbonate safety glasses are a minimum safety precaution. Glasses with UVB protection are used in occupations where sunlight exposure is high. Eyewash stations are necessary where splash injuries or chemical exposures are possible. REF: Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 80: Auricular Disorders Test Bank Multiple Choice 1. During a routine physical examination, a provider notes a shiny, irregular, painless lesion on the top of one ear auricle and suspects skin cancer. What will the provider tell the patient about this lesion? a. A biopsy should be performed. b. Immediate surgery is recommended. c. It is benign and will not need intervention. d. This is most likely malignant. ANS: A This lesion is characteristic of basal cell carcinoma, which is a slow-growing cancer least likely to metastasize. A biopsy should be performed to evaluate this. Immediate surgery is not necessary. Until a biopsy is performed, the provider cannot determine whether it is benign. REF: Definition and Epidemiology/Management 2. A primary care provider notes painless, hard lesions on a patient’s external ears that expel a white crystalline substance when pressed. What diagnostic test is indicated? a. Biopsy of the lesions b. Endocrine studies c. Rheumatoid factor d. Uric acid chemical profile ANS: D These lesions are consistent with gout and uric acid deposits. The provider should evaluate this by ordering a uric acid chemical profile. Biopsy is indicated for any small, crusted, ulcerated, or indurated lesion that doesn’t heal. Rheumatoid nodules indicate a need for rheumatoid profiles. Endocrine studies are ordered for patients with calcification nodules. REF: Definition and Epidemiology/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 81:Cerumen Impaction Test Bank Multiple Choice 1. A provider is recommending a cerumenolytic for a patient who has chronic cerumen buildup. The provider notes that the patient has dry skin in the ear canal. Which preparation is FDA approved for this use? a. Carbamide peroxide b. Hydrogen peroxide c. Liquid docusate sodium d. Mineral oil ANS: A Any preparation with carbamide peroxide is FDA approved as a cerumenolytic. Patients with dry skin in the ear canal should not use any product containing hydrogen peroxide. Liquid docusate sodium and mineral oil are often used, but do not have specific FDA approval. REF: Management 2. A patient complains of otalgia and difficulty hearing from one ear. The provider performs an otoscopic exam and notes a dark brown mass in the lower portion of the external canal blocking the patient’s tympanic membrane. What is the initial action? a. Ask the patient about previous problems with that ear b. Irrigate the canal with normal saline c. Prescribe a ceruminolytic agent for that ear d. Use a curette to attempt to dislodge the mass ANS: A Before attempting to remove impacted cerumen, the provider must determine whether the TM is intact and should ask about pressure equalizing ear tubes, a history of ruptured TM, and previous ear surgeries. Once the TM is determined to be intact, the other methods may be attempted, although the curette should only be used if the mass is in the lateral third of the ear canal. REF: Management 3. A child has recurrent impaction of cerumen in both ears and the parent asks what can be done to help prevent this. What will the provider recommend? a. Clean the outer ear and canal with a soft clothTest Bank 2 b. Removing cerumen with a cotton-tipped swab c. Try thermal-auricular therapy when needed d. Use an oral irrigation tool to remove cerumen ANS: A Parents should be instructed to use a soft cloth to clean the outer ear and canal only. Use of a cotton-tipped swab or any other implement may push cerumen deeper into the canal and risk damaging the tympanic membrane. Thermal-auricular therapy is not recommended. Oral irrigation tools have high pressure and a risk of damage to the tympanic membrane. REF: Education and Health PromotionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 82: Cholesteatoma Test Bank Multiple Choice 1. A child is diagnosed as having a congenital cholesteatoma. What is included in management of this condition? Select all that apply. a. Antibacterial treatment b. Insertion of pressure equalizing tubes c. Irrigation of the ear canal d. Removal of debris from the ear canal e. Surgery to remove the lesion ANS: A, D, E Cholesteatoma is treated with antibiotics, removal of debris from the ear canal, and possibly surgery. PETs and irrigation of the ear canal are not part of treatment for cholesteatoma. REF: Management 2. A young child has a pale, whitish discoloration behind the tympanic membrane ™. The provider notes no scarring on the TM and no retraction of the pars flaccida. The parent states that the child has never had an ear infection. What do these findings most likely represent? a. Chronic cholesteatoma b. Congenital cholesteatoma c. Primary acquired cholesteatoma d. Secondary acquired cholesteatoma ANS: B Patients without history of otitis media or perforation of the TM most likely have congenital cholesteatoma. Primary acquired cholesteatoma will include retraction of the pars flaccida. Secondary acquired cholesteatoma has findings associated with the underlying etiology. REF: Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 83: Impaired Hearing Test Bank Multiple Choice 1. Which are risk factors for developing hearing loss caused by presbycusis? Select all that apply. a. Diabetes b. GERD c. High blood pressure d. Liver disease e. Smoking ANS: A, C, E Presbycus is a gradual degeneration within the cochlea that accompanies aging. Diabetes, high blood pressure, and smoking may hasten these changes. GERD and liver disease are not associated with an increased rate of changes. REF: Pathophysiology 2. A child who has recurrent otitis media fails a hearing screen at school. The provider suspects which type of hearing loss in this child? a. Central b. Conductive c. Mixed type d. Sensorineural ANS: B A common cause of conductive loss is fluid in the middle ear as a result of chronic otitis media with effusion. Central hearing loss is related to CNS disorders. Mixed type hearing loss is related to causes of both conductive and sensorineural hearing loss. Sensorineural hearing loss is caused by damage to the structures in the inner ear, usually caused by infection, barotrauma, or trauma. REF: Pathophysiology 3. A screening audiogram on a patient is abnormal. Which test may the primary provider perform next to further evaluate the cause of this finding? a. Impedance audiometry b. Pure tone audiogram c. Speech reception testTest Bank 2 d. Tympanogram ANS: D A screening tympanogram may be performed by a primary provider to determine tympanic membrane mobility and may help in identifying the presence of infection, fluid, or changes in middle ear pressure. The other tests are performed by audiologists, not primary care providers. REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 84: Inner Ear Disturbances Test Bank Multiple Choice 1. A patient is suspected of having vestibular neuritis. Which finding on physical examination is consistent with this diagnosis? a. Facial palsy and vertigo b. Fluctuating hearing loss and tinnitus c. Spontaneous horizontal nystagmus d. Vertigo with changes in head position ANS: C Many patients with vestibular neuritis will exhibit spontaneous horizontal or rotary nystagmus, away from the affected ear. Facial palsy with vertigo occurs with Ramsay Hunt syndrome, caused by herpes zoster. Fluctuating hearing loss with tinnitus is common in Meniere’s disease. Tinnitus may occur with vestibular neuritis, but hearing loss does not occur. Patients with benign paroxysmal positional vertigo will exhibit vertigo associated with changes in head position. REF: Vestibular Neuritis/Physical Examination/Differential Diagnosis 2. Which symptoms may occur with vestibular neuritis? Select all that apply. a. Disequilibrium b. Fever c. Hearing loss d. Nausea and vomiting e. Tinnitus ANS: A, D, E Vestibular neuritis can cause severe vertigo, disequilibrium, nausea, vomiting, and tinnitus, but not fever or hearing loss. REF: Vestibular Neuritis/Clinical Presentation/Physical Examination 3. A patient reports several episodes of acute vertigo, some lasting up to an hour, associated with nausea and vomiting. What is part of the initial diagnostic workup for this patient? a. Audiogram and MRI b. Auditory brainstem testing c. ElectrocochleographyTest Bank 2 d. Vestibular testing ANS: A An audiogram and MRI are part of basic testing for Meniere’s disease. The other testing may be performed by an otolaryngologist after referral. REF: Meniere’s Disease/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 85: Otitis Externa Test Bank Multiple Choice 1. A patient reports a feeling of fullness and pain in both ears and the practitioner elicits exquisite pain when manipulating the external earstructures. What is the likely diagnosis? a. Acute otitis externa b. Acute otitis media c. Chronic otitis externa d. Otitis media with effusion ANS: A This patient’s symptoms are classic for acute otitis externa. Chronic otitis externa more commonly presents with itching. Acute otitis media is accompanied by fever and tympanic membrane inflammation, but not external canal inflammation. Otitis media with effusion causes a sense of fullness but not pain. REF: Clinical Presentation/Box 85-1:Differential Diagnosis 2. Which are risk factors for developing otitis externa? Select all that apply. a. Cooler, low-humidity environments b. Exposure to someone with otitis externa c. Having underlying diabetes mellitus d. Use of ear plugs and hearing aids e. Vigorous external canal hygiene ANS: C, D, E Otitis externa is a cellulitis of the external canal that develops when the integrity of the skin is compromised. Diabetes mellitus predisposes patients to skin disorders. Using devices that cause moisture retention and irritation will increase the risk. Vigorous cleansing removes protective cerumen. Warm, high-humidity environments increase risk. The disease is not contagious. REF: Definition and Epidemiology/Pathophysiology 3. A patient has an initial episode otitis external associated with swimming. The patient’s ear canal is mildly inflamed and the tympanic membrane is not involved. Which medication will be ordered? a. Cipro HCTest Bank 2 b. Fluconazole c. Neomycin d. Vinegar and alcohol ANS: A In the absence of a culture, the provider should choose a medication that is effective against both P. aeruginosa and S. aureus. Cipro HC covers both organisms and also contains a corticosteroid for inflammation. Fluconazole is an oral anti-fungal medication used when fungal infection is present. Neomycin alone does not cover these organisms. Vinegar and alcohol is used to treat mild fungal infections. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 86: Otitis Media Test Bank Multiple Choice 1. Which symptoms in children are evaluated using a parent-reported scoring system to determine the severity of pain in children with otitis media? Select all that apply. a. Appetite b. Difficulty sleeping c. Level of cooperation d. Poorhearing e. Tugging on ears ANS: A, B, E Decreased appetite, difficulty sleeping, and tugging on ears are part of the Acute Otitis Media Severity of Symptom Scale used to evaluate pediatric pain. Children may refuse to cooperate for reasons other than pain. Poor hearing is not part of the pain assessment. REF: Clinical Presentation and Physical Examination 2. Which patient may be given symptomatic treatment with 24 hours follow-up assessment without initial antibiotic therapy? a. A 36 month old with fever of 38.5°C, mild otalgia, and red, non-bulging TM b. A 4 year old, afebrile child with bilateral otorrhea c. A 5 year old with fever of 38.0° C, severe otalgia, and red, bulging TM d. A 6 month old with fever of 39.2°C, poor sleep and appetite and bulging TM ANS: A Children older than 24 months with fever less than 39° C and non-severe symptoms may be watched for 24 hours with symptomatic treatment. Children with otorrhea, those with severe AOM, and any children with fever greater than 39° C should be given antibiotics. REF: Management 3. A pediatric patient has otalgia, fever of 38.8° C, and a recent history of upper respiratory examination. The examiner is unable to visualize the tympanic membranes in the right ear because of the presence of cerumen in the ear canal. The left tympanic membrane is dull gray with fluid levels present. What is the correct action?Test Bank 2 a. Perform a tympanogram on the right ear b. Recommend symptomatic treatment for fever and pain c. Remove the cerumen and visualize the tympanic membrane d. Treat empirically with amoxicillin 80 to 90 mg/kg/day ANS: C The AAP 2013 guidelines strongly recommend visualization of the tympanic membrane to accurately diagnose otitis media and not to treat based on symptoms alone. The practitioner should attempt to remove the cerumen in order to visualize the tympanic membrane. A tympanogram cannot be performed when cerumen is blocking the canal. Because the child may have an acute ear infection, antibiotics may be necessary. REF: Clinical Presentation and Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 87: Tympanic Membrane Perforation Test Bank Multiple Choice 1. A patient reports ear pain and difficulty hearing. An otoscopic examination reveals a small tear in the tympanic membrane of the affected ear with purulent discharge. What is the initial treatment for this patient? a. Insert a wick into the ear canal b. Irrigate the earcanal to remove the discharge c. Prescribe antibiotic ear drops d. Refer the patient to an otolaryngologist ANS: C This perforation is most likely due to infection and should be treated with antibiotic ear drops. Wicks are used for otitis externa. The ear canal should not be irrigated to avoid introducing fluid into the middle ear. It is not necessary to refer unless the perforation does not heal. REF: Clinical Presentation and Physical Examination/Management 2. A patient reports ear pain after being hit in the head with a baseball. The provider notes a perforated tympanic membrane. What is the recommended treatment? a. Orderantibiotic ear drops if signs of infection occur b. Prescribe analgesics and follow up in 1 to 2 days c. Reassure the patient that this will heal without problems d. Refer the patient to an otolaryngologist for evaluation ANS: D Patients with traumatic or blast injuries causing perforations of the tympanic membranes should be referred to specialists to determine whether damage to inner ear structures has occurred. For an uncomplicated perforation, the other interventions are all appropriate. REF: Complications and Indications for ReferralButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 88: Chronic NasalCongestion and Discharge Test Bank Multiple Choice 1. A patient reports persistent nasal blockage, nasal discharge, and facial pain lasting on the right side for the past 4 months. There is no history of sneezing or eye involvement. The patient has a history of seasonal allergies and takes a non-sedating antihistamine. What does the provider suspect is the cause of these symptoms? a. Allergic rhinitis b. Autoimmune vasculitides c. Chronic rhinosinusitis d. Rhinitis medicamentosa ANS: C Chronic rhinosinusitis is present when symptoms occur longer than 3 months. Sneezing and itchy, watery eyes tend to occur with allergic rhinitis. Autoimmune vasculitides affects upper and lower respiratory tracts as well as the kidneys. Rhinitis medicamentosa occurs with use of nasal decongestants and not oral antihistamines. REF: Clinical Presentation/Differential Diagnosis/Table 88-1: Comparison of Clinical Presentations of Chronic Rhinosinusitis and Allergic Rhinitis 2. A provider determines that a patient has chronic rhinosinusitis without nasal polyps. What is the first-line treatment for this condition? a. Intranasal corticosteroids b. Oral decongestants c. Systemic corticosteroids d. Topical decongestants ANS: A Intranasal corticosteroids are the mainstay of treatment for CRS. Oral decongestants should be used sparingly, only when symptoms are intolerable. Topical decongestants can cause rebound symptoms. Systemic steroids are not indicated. REF: Management 3. A pregnant woman develops nasal congestion with chronic nasal discharge. What is the recommended treatment for this patient? a. Intranasal corticosteroidsTest Bank 2 b. Prophylactic antibiotics c. Saline lavage d. Topical decongestants ANS: C Saline lavage is recommended for pregnancy rhinitis; the condition will resolve after delivery. There is no human data on the safety of intranasal corticosteroids during pregnancy. Prophylactic antibiotics are not indicated; this is not an infectious condition. Topical decongestants can cause rebound symptoms. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 89: Epistaxis Test Bank Multiple Choice 1. A patient has recurrent epistaxis without localized signs of irritation. Which laboratory tests may be performed to evaluate this condition? Select all that apply. a. BUN and creatinine b. CBC with platelets c. Liver function tests d. PT and PTT e. PT/INR ANS: B, D, E A CBC with platelets is part of the diagnostic workup along with coagulation studies. LFTs and renal function tests aren’t used to evaluate recurrent epistaxis. REF: Diagnostics 2. A patient is in the emergency department with unilateral epistaxis that continues to bleed after 15 minutes of pressure on the anterior septum and application of a topical nasal decongestant. The provider is unable to visualize the site of the bleeding. What is the next measure for this patient? a. Chemical cautery b. Electrocautery c. Nasalpacking d. Petrolatum ointment ANS: C Nasal packing is used if bleeding continues after initial measures. Chemical cautery and electrocautery are used only if the site of bleeding is visualized. Petrolatum ointment is applied once the bleeding is stopped. REF: Management/Anterior Epistaxis 3. A patient has bilateral bleeding from the nose with bleeding into the pharynx. What is the initial intervention for this patient? a. Apply firm, continuous pressure to the nostrils b. Assess airway safety and vital signs c. Clear the blood with suction to identify site of bleedingTest Bank 2 d. Have the patient sit up straight and tilt the head forward ANS: B Bilateral epistaxis into the pharynx is more indicative of a posterior bleed which is more likely to be severe. The most important intervention is to ensure airway safety and determine stability of vital signs. Other measures are taken as needed. REF: Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 90: NasalTrauma Test Bank Multiple Choice 1. A provider performs a nasal speculum examination on a patient who sustained nasal trauma in a motor vehicle accident. The provider notes marked swelling of the nose, instability and crepitus of the nasal septum with no other facial bony abnormalities and observes a rounded bluish mass against the nasal septum. Which action is necessary at this time? a. CT scan of facial structures b. Ice packs to reduce facial swelling c. Surgery to reduce the nasal fracture d. Urgent drainage of the mass ANS: D A rounded bluish or purplish mass indicates a septal hematoma and must be drained urgently for cosmetic purposes to prevent loss of nasal cartilage caused by loss of blood supply to this area. This patient has no signs of facial fractures, so this exam may be deferred. Ice packs are part of ongoing management, but not a priority. The nasal fracture may be reduces within the first 3 to 5 days after injury. REF: Physical Examination/Management/Complications 2. An alert, irritable 12-month-old child is brought to the emergency department by a parent who reports that the child fell into a coffee table. The child has epistaxis, periorbital ecchymosis, and nasal edema. Nares are patent and the examiner palpates instability and point tenderness of the nasal septum. The orbital structures appear intact. What is an urgent action for this patient? a. Assessment of tetanus vaccination b. Ice, head elevation, and analgesia c. Immediate nasal reduction surgery d. Involvement of social services ANS: D Young children and infants generally do not engage in activities that cause the high impact needed to cause a nasal fracture and nasal structures, which have more cartilage than adults, are at much lower risk of fracture. Child abuse must be suspected in this case. Assessment of tetanus status and application of symptomatic treatment may be ongoing, but are not urgent. Nasal reduction surgery may be deferred for several days. REF: Physical Examination/Management/Lifespan Considerations/PediatricTest Bank 2 3. A child is hit with a baseball bat during a game and sustains an injury to the nose, along with a transient loss of consciousness. A health care provider at the game notes bleeding from the child’s nose and displacement of the septum. What is the most important intervention at this time? a. Apply ice to the injured site to prevent airway occlusion b. Immobilize the child’s head and neck and call 911 c. Place nasal packing in both nares to stop the bleeding d. Turn the child’s head to the side to prevent aspiration of blood ANS: B Nasal trauma resulting in loss of consciousness and possible neck injury are emergencies. The provider should take cervical spine precautions and call 911 for transport to an emergency room. The other interventions may be performed once the child’s head and neck are stable. REF: Clinical PresentationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 91: Rhinitis Test Bank Multiple Choice 1. A patient has recurrent sneezing, alterations in taste and smell, watery, itchy eyes, and thin, clear nasal secretions. The provider notes puffiness around the eyes. The patient’s vital signs are normal. What is the most likely diagnosis for this patient? a. Acute sinusitis b. Allergic rhinitis c. Chronic sinusitis d. Viral rhinitis ANS: B Patients with symptoms described above typically have allergic rhinitis. Sinusitis causes facial pain, fever, and purulent discharge. Viral rhinitis will also cause purulent discharge and other symptoms of URI. REF: Allergic Rhinitis/Clinical Presentation 2. A patient has seasonal rhinitis symptoms and allergy testing reveals sensitivity to various trees and grasses. What is the first-line treatment for this patient? a. Antihistamine spray b. Intranasal cromolyn c. Intranasal steroids d. Oral antihistamines ANS: C Intranasal steroids are the mainstay of treatment and are the most effective medication for preventing symptoms. Antihistamine sprays are helpful, but are not first-line treatments. Intranasal cromolyn can be effective, but must be used four times daily. Oral antihistamines are used in conjunction with intranasal steroids, but are less effective than the steroids. REF: Allergic Rhinitis/Medications 3. A patient is concerned about frequent nasal stuffiness and congestion that begins shortly after getting out of bed in the morning. The patient denies itching and sneezing. A physical examination reveals erythematous nasal mucosa with scant watery discharge. What treatment will the provider recommend for this patient? a. Consultation for immunotherapyTest Bank 2 b. Daily intranasal steroids c. Oral antihistamines each morning d. Oral decongestants as needed ANS: B This patient has symptoms of vasomotor or idiopathic rhinitis. Intranasal steroids are an effective treatment. Immunotherapy is not effective. This type of rhinitis typically does not respond to antihistamines. Oral decongestants are effective, but are best used around the clock, not just prn. REF: Vasomotor Rhinitis/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 92: Sinusitis Test Bank Multiple Choice 1. A patient is concerned about frequent nasal stuffiness and congestion that begins shortly after getting out of bed in the morning. The patient denies itching and sneezing. A physical examination reveals erythematous nasal mucosa with scant watery discharge. What treatment will the provider recommend for this patient? a. Consultation for immunotherapy b. Daily intranasal steroids c. Oral antihistamines each morning d. Oral decongestants as needed ANS: A Intranasal steroids should be considered for symptomatic relief for patients with sinusitis, especially those with allergic rhinitis. Oral mucolytics have little support in efficacy. Saline solution rinses may provide some relief, but there is no evidence to support their usefulness. Topical decongestants do decrease nasal congestion and edema, but the potential harm of rebound congestion requires recommendation with caution. REF: Management 2. Which are potential complications of chronic or recurrent sinusitis? Select all that apply. a. Allergic rhinitis b. Asthma c. Meningitis d. Orbital infection e. Osteomyelitis ANS: C, D, E Complications of chronic or recurrent sinusitis include spread of infection to other tissues and may cause meningitis, orbital cellulitis, and osteomyelitis. Allergic rhinitis and asthma are associated with chronic sinusitis, but not complications of this condition. REF: Complications 3. A patient has nasal congestion, fever, purulent nasal discharge, headache, and facial pain and begins treatment with amoxicillin-clavulanate. At a follow-up visit 10 days after initiation of treatment, the patient continues to have purulent discharge, congestion, and facial pain without fever. What is the next course of action for this patient?Test Bank 2 a. A CT scan of the paranasal sinuses b. A referral to an otolaryngologist c. A second course of amoxicillin-clavulanate d. A trial of azithromycin ANS: C This patient may have subacute sinusitis and may benefit from a second course of the antibiotic. The lack of fever shows improvement, so this antibiotic may be used. CT scan is usually not performed in adults unless other complications are present or suspected. Referral to an otolaryngologist is necessary if no improvement after the second course of antibiotics. Azithromycin is not used in adults unless pregnant, due to resistance patterns. REF: Clinical Presentation/Diagnostics/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 93: Smell and Taste Disturbances Test Bank Multiple Choice 1. An elderly patient has a permanent loss of the sense of smell and diminished taste. What will be included in teaching this patient about managing these symptoms? Select all that apply. a. Avoiding perfumes and perfumed soaps b. Eating regular meals at scheduled times c. Putting dates on food in the refrigerator d. The importance of installing smoke detectors e. Using gas rather than electrical appliances ANS: B, C, D Patients with diminished or absent smell or taste are at risk because of the inability to detect spoiled foods or gas stoves and a tendency to lose interest in eating. It is not necessary to avoid perfumes, but patients should be counseled to eat regular meals, put dates on foods in the refrigerator, and install smoke detectors. They should avoid gas stoves. REF: Geriatrics/Patient and Family Education and Health Promotion 2. A patient reports that meat smells different than it used to. What word describes this dysfunction? a. Aliageusia b. Anosmia c. Dysgeusia d. Parosmia ANS: D Parosmia refers to smell distortion. Aliageusia is unpleasant taste. Anosmia is a loss of the sense of smell. Dysgeusia is persistent taste. REF: Definition and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 94: Tumors and Polyps of the Nose Test Bank Multiple Choice 1. A provider examines a patient who has chronic nasal obstruction, respiratory tract symptoms, and generalized malaise. An examination of the nasal mucosa reveals ulceration of the nasal septum. What is the most important action when caring for this patient? a. Administering prednisone b. Obtaining a chest radiograph c. Performing laboratory tests d. Referring to a specialist ANS: D This patient has symptoms of granulomatosis with polyangitis (GPA) and should be referred as soon as the disease is suspected. The other actions will be taken, but referral is the most important. REF: Granulomatosis with Polyangitis/Clinical Presentation/Management and Indications for Referral or Hospitalization 2. A patient reports chronic nasal obstruction and difficulty distinguishing smells. The provider examines the nares with a nasal speculum and observes several grapelike lesions in both nostrils. What is the likely cause of this patient’s symptoms? a. Chronic sinusitis b. Nasal polyps c. Squamous cell carcinoma d. Vascular benign tumor ANS: B Polyps cause obstruction and olfactory dysfunction and appear as grapelike lesions on the nasal mucosa. Most malignant neoplasms are asymptomatic until late in the course. Chronic sinusitis characteristically produces inflammation and purulent discharge. REF: Clinical Presentation 3. A patient reports chronic nasal obstruction and recurrent epistaxis. Which type of nasal mass is likely? a. Inverted papilloma b. Nasal polyp c. Paranasal lymphomaTest Bank 2 d. Squamous cell carcinoma ANS: A Inverted papillomas are benign tumors of the nasal mucosa and are highly vascular with frequent bleeding. Nasal polyps typically do not bleed and are associated with allergies. Paranasal lymphoma and squamous cell carcinoma are not initially associated with bleeding. REF: PathophysiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 95: Dental Abscess Test Bank Multiple Choice 1. A patient has been taking amoxicillin for treatment of a dental abscess. In a follow-up visit, the provider notes edema of the eyelids and conjunctivae. What is the next action? a. Hospitalize the patient for an endodontist consultation b. Prescribe amoxicillin clavulanate for 10 to 14 days c. Recommend follow up with a dentist in 2 to 3 days d. Suggest using warm compresses to the eyes for comfort ANS: A This patient has signs of complications and requires hospitalization with management by a dentist or endodontist. Changing the antibiotic without consultation is not recommended. Prompt hospitalization is required. REF: Indications for Referral or Hospitalization 2. A patient reports tooth pain in a lower molar and the provider notes a mobile tooth with erythema and edema of the surrounding tissues without discharge. Which is the initial course of action by the provider? a. Perform an incision and drainage of the edematous tissue b. Prescribe amoxicillin and refer to a dentist in 2 to 3 days c. Recommend oral antiseptic rinses and follow up in one week d. Refer to an oral surgeon for emergency surgery ANS: B The primary provider may prescribe antibiotics, especially if the surrounding tissues are infected. Patients should follow up with a dentist in 2 to 3 days. The primary provider generally does not perform I&D; this should be done by the dentist. Follow up should be with a dentist in 2 to 3 days, not one week. Emergency surgery is indicated if there is a question of airway compromise. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 96: Diseases ofthe Salivary Glands Test Bank Multiple Choice 1. A patient has a chronic swelling of the parotid gland that is unresponsive to antibiotics and which has not increased in size. Which diagnostic test is indicated? a. Computed tomography b. Fine needle aspiration c. Magnetic resonance imaging d. Plain film radiography ANS: B Chronic lesions may represent tuberculosis or malignancies, so fine needle aspiration is indicated to rule out these diseases. Radiological studies are used to identify the extent of disease, but are usually not diagnostic. REF: Diagnostics 2. A patient reports painful swelling in the mouth with increased pain at mealtimes. The provider notes a mass in the salivary gland region. What is the likely cause of these symptoms? a. Basal cell adenoma b. Sialolithiasis c. Sjogren syndrome d. Warthin’s tumor ANS: B Sialolithiasis is a non-infectious salivary gland disorder characterized by pain at mealtimes caused by blockage of the salivary duct by stones. Basal cell adenoma is a noninfectious cause of salivary gland inflammation that is generally painless. Sjogren syndrome manifests with xerostomia and abnormal taste. Warthin’s tumor causes a painless, unilateral mass. REF: Clinical Presentation 3. A patient has parotitis and cultures are positive for actinomycosis. What is the initial treatment for this condition? a. Intravenous penicillin b. Oral clindamycin c. Oral erythromycinTest Bank 2 d. Topical antibiotics ANS: A IV penicillin, followed by oral PCN for several months is indicated for actinomycosis. Clindamycin and erythromycin are used for PCN allergy. Topical antibiotics are not effective. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 97:Epiglottitis Test Bank Multiple Choice 1. An adult patient has epiglottitis secondary to a chemical burn. Which medication will be given initially to prevent complications? a. Chloramphenicol b. Clindamycin c. Dexamethasone d. Metronidazole ANS: C This case of epiglottitis does not have an infectious cause, so antibiotics are not given unless there are symptoms of infection. A corticosteroid can decrease the need for intubation. REF: Management 2. An adult patient is seen in clinic with fever, sore throat, and dysphagia. Which diagnostic test will the provider order to confirm a diagnosis of epiglottitis? a. Blood cultures b. Complete blood count c. Fiberoptic nasopharyngoscopy d. Lateral neck film ANS: C Fiberoptic nasopharyngoscopy allows direct visualization of the epiglottis and is used increasingly with adult patients suspected of having epiglottitis. Blood cultures and a CBC may be drawn as part of the workup to help guide antimicrobial therapy, but are not diagnostic. A lateral neck film is not always diagnostic with adults. REF: Diagnostics 3. The provider sees a child with a history of high fever and sore throat. When entering the exam room, the provider finds the child sitting in the tripod position and notes stridor, drooling, and anxiety. What is the initial action for this patient? a. Administer empiric intravenous antibiotics and steroids b. Have the child lie down and administer high-flow, humidified oxygen c. Obtain an immediate consultation with an otolaryngologist d. Perform a thorough examination of the oropharynxTest Bank 2 ANS: C Patients with suspected epiglottitis, with high fever, sore throat, stridor, drooling, and respiratory distress, should be referred immediately to otolaryngology. Starting an IV or having the child lie down will increase distress and may precipitate laryngospasm. The throat should not be examined because it may cause laryngospasm REF: Diagnostics/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 98: Oral Infections Test Bank Multiple Choice 1. A patient reports painful oral lesions 3 days after feeling pain and tingling in the mouth. The provider notes vesicles and ulcerative lesions on the buccal mucosa. What is the most likely cause of these symptoms? a. Bacterial infection b. Candida albicans c. Herpes simplex virus d. Human papilloma virus ANS: C HSV infections generally start with a prodrome of tingling, pain, and burning followed by vesicular and ulcerative lesions. Bacterial infection presents with inflammation of the gingiva, bleeding, and ulceration with or without purulent discharge. Candida albicans appear as white, cottage cheese-like lesions that may be removed, but may cause bleeding when removed. HPV manifests as white, verrucous lesions individually or in clusters. REF: Clinical Presentation 2. A patient has gingival inflammation with several areas of ulceration and a small amount of purulent discharge. What is required to diagnose this condition? a. Culture and sensitivity b. Microscopic exam of oral scrapings c. Physical examination d. Tzanck smear ANS: C This patient has symptoms consistent with gingivitis, which may be diagnosed by physical examination alone. Cultures are not necessary unless systemic disease is present. A microscopic exam of oral scrapings to look for hyphae may be performed to diagnose candida infections. A Tzanck smear is performed to confirm a diagnosis of herpes simplex. REF: Clinical Presentation/Diagnostics 3. A patient has painful oral lesions and the provider notes several white, verrucous lesions in clusters throughout the mouth. What is the recommended treatment for this patient? a. Nystatin oral suspensionTest Bank 2 b. Oral acyclovir c. Oralhygiene measures d. Surgical excision ANS: D White, verrucous lesions in clusters are diagnostic for HPV infection which is treated with surgical excision. Nystatin suspension is given for candida infection. Oral acyclovir is used for HSV infection. Oral hygiene measures are used for gingivitis. REF: Clinical Presentation/ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 99: Parotitis Test Bank Multiple Choice 1. Which physical examination finding suggests viral rather than bacterial parotitis? a. Clear discharge from Stensen’s duct b. Enlargement and pain of affected glands c. Gradual reduction in saliva production d. Unilateral edema of parotid glands ANS: A Viral parotitis generally produces clear discharge. Enlargement and pain of affected glands may be non-specific or is associated with TB infection. A gradual reduction in saliva, resulting in xerostomia, is characteristic of HIV infection. Unilateral edema is more often bacterial. REF: Clinical Presentation 2. A patient who has acute suppurative parotitis has been taking amoxicillin-clavulanate for 4 days without improvement in symptoms. The provider will order an antibiotic for Methicillin-resistant S. aureus. Which other measure may be helpful? a. Cool compresses b. Discouraging chewing gum c. Surgical drainage d. Topical corticosteroids ANS: C If improvement does not occur after 3 to 4 days of antibiotics, surgical drainage is appropriate. Warm compresses are recommended for comfort. Chewing gum and other sialogogues to stimulate the production of saliva are recommended. Steroids are questionable and topical steroids will have little effect. REF: Management 3. What are factors associated with acute suppurative parotitis? Select all that apply. a. Allergies b. Anticholinergic medications c. Diabetes mellitus d. HypervolemiaTest Bank 2 e. Radiotherapy ANS: B, C, E Anticholinergic medications decrease salivary flow and increase the risk for parotitis. Chronic diseases, including diabetes mellitus, can increase the risk. Radiotherapy and other procedures may increase the risk. Allergies and hypervolemia do not increase the risk. REF: Definitions and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 100: Peritonsillar Abscess Test Bank Multiple Choice 1. An adolescent has fever, chills, and a severe sore throat. On exam, the provider notes foulsmelling breath and a muffled voice with marked edema and erythema of the peritonsillar tissue. What will the primary care provider do? a. Evaluate for possible epiglottitis b. Perform a rapid strep and throat culture c. Prescribe empiric oral antibiotics d. Refer the patient to an otolaryngologist ANS: D This patient has clinical signs of peritonsillar abscess, which may be diagnosed on clinical signs alone. Patients with peritonsillar abscess should be referred to an otolaryngologist for possible I&D of the abscess and hospitalization for IV antibiotics. A rapid strep and culture are not indicated. Oralantibiotics generally do not work. REF: Clinical Presentation/Management 2. A patient is diagnoses with peritonsillar abscess and will be hospitalized for intravenous antibiotics. What additional treatment will be required? a. Intubation to protect the airway b. Needle aspiration of the abscess c. Systemic corticosteroid administration d. Tonsillectomy and adenoidectomy ANS: B Needle aspiration, antibiotics, pain medication, and hydration can effectively treat peritonsillar abscess. Intubation is not performed unless the airway is compromised. Systemic corticosteroid administration is useful, but not required in all cases. Tonsillectomy alone is sometimes performed if recurrent tonsillitis or peritonsillar abscess is present. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 101:Pharyngitis and Tonsillitis Test Bank Multiple Choice 1. A patient has sore throat, a temperature of 38.5° C, tonsillar exudates, and cervical lymphadenopathy. What will the provider do next to manage this patient’s symptoms? a. Order an antistreptolysin O titer b. Perform a rapid antigen detection test c. Prescribe empiric penicillin d. Refer to an otolaryngologist ANS: B The RADT is performed initially to determine whether GAS is present. The ASO titer is not used during initial diagnostic screening. Penicillin should not be given empirically. A referral to a specialist is not required for GAS infection. REF: Diagnostics 2. A patient reports a sudden onset of sore throat, fever, malaise, and cough. The provider notes mild erythema of the pharynx and clear rhinorrhea without cervical lymphadenopathy. What is the most likely cause of these symptoms? a. Allergic pharyngitis b. Group A streptococcus c. Infectious mononucleosis d. Viral pharyngitis ANS: D Viral pharyngitis will cause sore throat, fever, and malaise and is often accompanied by URI symptoms of cough and runny nose. Allergic pharyngitis usually also causes dryness. GAS causes high fever, cervical adenopathy, and marked erythema with exudate. Infectious mononucleosis will cause an exudate along with cervical adenopathy. REF: Clinical Presentation/Physical Examination 3. A school-age child has had 5 episodes of tonsillitis in the past year and 2 episodes the previous year. The child’s parent asks the provider if the child needs a tonsillectomy. What will the provider tell this parent? a. Current recommendations do not support tonsillectomy for this child. b. If there is one more episode in the next 6 months, a tonsillectomy is necessary.Test Bank 2 c. The child should have radiographic studies to evaluate the need for tonsillectomy. d. Tonsillectomy is recommended based on this child’s history. ANS: A Recommendations suggest 6 to 7 documented episodes of GAS within 1 year, 5/year for 2 consecutive years, or 3/year for 3 years. Radiographic studies are not indicated. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 102:Acute Bronchitis Test Bank Multiple Choice 1. An adult patient who had pertussis immunizations as a child is exposed to pertussis and develops a runny nose, low-grade fever, and upper respiratory illness symptoms without a paroxysmal cough. What is recommended for this patient? a. Azithromycin daily for 5 days b. Isolation if paroxysmal cough develops c. Pertussis vaccine booster d. Symptomatic care only ANS: A Adults previously immunized against pertussis may still get the disease without the classic whooping cough sign seen in children and are contagious from the beginning of the catarrhal stage of runny nose and common cold symptoms. Azithromycin or other macrolide antibiotics are useful for reducing symptoms and for decreasing shedding of bacteria to limit spread of the disease. Patients should be isolated for 5 days from the start of treatment. Pertussis vaccine booster will not alter the course of the disease once exposed. Symptomatic care only will not reduce symptoms or decrease disease spread. REF: ManagementQ uestion 2 of 3 2. A patient develops a dry, non-productive cough and is diagnosed with bronchitis. Several days later, the cough becomes productive with mucoid sputum. What may be prescribed to help with symptoms? a. Antibiotic therapy b. Antitussive medication c. Bronchodilator treatment d. Mucokinetic agents ANS: B Antitussive medications are occasionally useful for short-term relief of coughing. Antibiotic therapy is generally not needed and should be avoided unless a bacterial cause is likely. Bronchodilator medications show no demonstrated reduction in symptoms and are not recommended. Mucokinetic agents have no evidence to support their use. REF: Communication and Language Development 3. A patient develops acute bronchitis and is diagnosed as having influenza. Which medication will help reduce the duration of symptoms in this patient?Test Bank 2 a. Azithromycin b. Clindamycin c. Oseltamivir d. Trimethoprim-sulfamethoxazole ANS: C Oseltamivir is an antiviral medication used to reduce the severity and duration of symptoms of influenza. The other medications are antibacterial medications and not effective to treat influenza. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 103: Asthma Test Bank Multiple Choice 1. A patient who has asthma calls the provider to report having a peak flow measure of 75%, shortness of breath, wheezing, and cough, and tells the provider that the symptoms have not improved significantly after a dose of albuterol. The patient uses an inhaled corticosteroid medication twice daily. What will the provider recommend? a. Administering two more doses of albuterol b. Coming to the clinic for evaluation c. Going to the emergency department d. Taking an oral corticosteroid ANS: A The patient is experiencing an asthma exacerbation and should follow the asthma action plan (AAP) which recommends three doses of albuterol before reassessing. The peak flow is above 70%, so ED admission is not indicated. The patient may be instructed to come to the clinic for oxygen saturation and spirometry evaluation after administering the albuterol. An oral corticosteroid may be prescribed if the patient will be treated as an outpatient after following the AAP. REF: Management 2. An adult develops chronic cough with episodes of wheezing and shortness of breath. The provider performs chest radiography and other tests and rules out infection, upper respiratory, and gastroesophageal causes. Which test will the provider order initially to evaluate the possibility of asthma as the cause of these symptoms? a. Allergy testing b. Methacholine challenge test c. Peak expiratory flow rate d. Spirometry ANS: D Spirometry is recommended at the time of initial assessment to confirm the diagnosis of asthma. Allergy testing is performed only if allergies are a possible trigger. The methacholine challenge test is performed if spirometry is inconclusive. PEFR is generally used to monitor asthma symptoms. REF: DiagnosticsTest Bank 2 3. A patient is seen in clinic for an asthma exacerbation. The provider administers three nebulizer treatments with little improvement, noting a pulse oximetry reading of 90% with 2 L of oxygen. A peak flow assessment is 70%. What is the next step in treating this patient? a. Administer three more nebulizer treatments and reassess b. Admit to the hospital with specialist consultation c. Give epinephrine injections and monitor response d. Prescribe an oral corticosteroid medication ANS: B Patients having an asthma exacerbation should be referred if they fail to improve after three nebulizer treatments or three epinephrine injections, have a peak flow less than 70% and a pulse oximetry reading less than 90% on room air. Giving more nebulizer treatments or administering epinephrine are not indicated. The patient will most likely be given IV corticosteroids; oral corticosteroids would be given if the patient is managed as an outpatient. REF: Definition and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 104: Chest Pain (Noncardiac) Test Bank Multiple Choice 1. A patient comes to an emergency department with chest pain. The patient describes the pain is sharp and stabbing and reports that it has been present for several weeks. Upon questioning, the examiner determines that the pain is worse after eating. The patient reports getting relief after taking a friend’s nitroglycerin during one episode. What is the most likely cause of this chest pain? a. Aortic dissection pain b. Cardiac pain c. Esophageal pain d. Pleural pain ANS: C Pain that is constant for weeks or is sharp and stabbing is not likely to be cardiac in origin. Both esophageal and cardiac causes will be attenuated with sublingual nitroglycerin. Aortic dissection will cause an abrupt onset with the greatest intensity at the beginning of the pain. Pleural pain is usually related to deep breathing or cough.REF: Clinical Presentation 2. A patient has chronic chest pain that occurs after meals and the provider suspects gastroesophageal reflux disease (GERD). The provider prescribes a proton pump inhibitor and after 2 months the patient reports improvement in symptoms. What is the next action in treating this patient? a. Continue the proton pump inhibitor b. Order esophageal pH monitoring c. Refer the patient to a gastroenterologist d. Schedule an upper endoscopy ANS: A Often the effectiveness of treatment with a PPI is diagnostic in itself and is equal to or better than more invasive and expensive testing. As long as the patient continues to show improvement, there is no need to order tests or refer for evaluation.REF: Diagnostics 3. A high school athlete reports recent onset of chest pain that is aggravated by deep breathing and lifting. A 12-lead electrocardiogram in the clinic is normal. The examiner notes localized pain near the sternum that increases with pressure. What will the provider do next?Test Bank 2 a. Order a chest radiograph b. Prescribe an antibiotic c. Recommend an NSAID d. Refer to a cardiologist ANS: C This patient has symptoms consistent with chest wall pain because the chest pain occurs with specific movement and is easily localized. Since the ECG is normal, there is no need to refer to a cardiologist. The patient does not have symptoms of pneumonia so a radiograph or antibiotic is not needed. NSAIDs are recommended for comfort.REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 105: Chronic Cough Test Bank Multiple Choice 1. A young adult patient develops a cough persisting longer than 2 months. The provider orders pulmonary function tests and a chest radiograph, which are normal. The patient denies abdominal complaints. There are no signs of rhinitis or sinusitis and the patient does not take any medications. What will the provider evaluate next to help determine the cause of this cough? a. 24-hour esophageal pH monitoring b. Methacholine challenge test c. Sputum culture d. Tuberculosis testing ANS: B Chronic cough without other symptoms may indicate asthma. If PFTs are normal, a methacholine challenge test may be performed. 24-hour esophageal pH monitoring is sometimes performed to evaluate for GERD, but this patient does not have abdominal symptoms and this test is usually not performed because it is inconvenient. Sputum culture is not indicated. TB is less likely.REF: Diagnostics 2. A patient is recovering from Mycoplasma pneumoniae infection and has a persistent cough 6 weeks after the infection. What will the provider do? a. Perform chest radiography to assess for secondary infection b. Perform pulmonary function and asthma challenge testing c. Prescribe a second round of azithromycin to treat the persistent infection d. Reassure the patient that this is common after M. pneumoniae infection ANS: D Post-infection cough is common after M. pneumoniae infection and may persist up to 8 weeks after the infection; this type of cough generally needs no intervention. It is not necessary to perform chest radiography unless secondary infection is suspected. Antibiotics are not indicated. Unless the cough persists after 8 weeks, asthma testing is not indicated.REF: Definition and EpidemiologyTest Bank 2 3. A non-smoking adult with a history of cardiovascular disease reports having a chronic cough without fever or upper airway symptoms. A chest radiograph is normal. What will the provider consider initially as the cause of this patient’s cough? a. ACE inhibitor medication use b. Chronic obstructive pulmonary disease c. Gastroesophageal reflux disease d. Psychogenic cough ANS: A About 10% of patients taking ACE inhibitors will develop chronic cough. COPD, GERD, and psychogenic causes are possible, but given this patient’s cardiovascular history, the possibility of ACE inhibitor- induced cough should be investigated initially.REF: Differential DiagnosisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 106: Chronic Obstructive Pulmonary Disease Test Bank Multiple Choice 1. Which is characteristic of chronic bronchitis and not emphysema? a. Damage to the alveolar wall b. Destruction of alveolar architecture c. Mild alteration in lung tissue compliance d. Mismatch of ventilation and perfusion ANS: C Chronic bronchitis causes much less parenchymal damage than emphysema does, so there is milder alteration in lung tissue compliance. The other symptoms are characteristic of emphysema.REF: Pathophysiology 2. A patient with chronic obstructive pulmonary disease and reports daily symptoms of dyspnea and cough. Which medication will the prescriber order? a. Ipratropium bromide b. Pirbuterol acetate c. Salmeterol xinafoate d. Theophylline ANS: A Ipratropium bromide is an anticholinergic medication and is used as first-line therapy in patients with daily symptoms. Pirbuterol acetate and salmeterol xinafoate are both beta2-adrenergics and are used to relieve bronchospasm; pirbuterol is a short-term medication used for symptomatic relief and salmeterol is a long-term medication useful for reducing nocturnal symptoms. Theophylline is a third-line agent.REF: Management 3. Which test is most diagnostic for chronic obstructive pulmonary disease? a. COPDAssessment Test b. Forced expiratory time maneuver c. Lung radiograph d. Spirometry for FVC and FEV1 ANS: DTest Bank 2 Spirometry testing is the gold standard for diagnosis and assessment of COPD because it is reproducible and objective. The forced expiratory time maneuver is easy to perform in a clinic setting and is a good screening to indicate a need for confirmatory spirometry. Lung radiographs are non-specific, but may indicate hyperexpansion of lungs. The COPD assessment test helps measure health status impairment in persons already diagnosed with COPD.REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 107: Dyspnea Test Bank Multiple Choice 1. A young adult patient without a previous history of lung disease has an increased respiratory rate and reports a feeling of ―not getting enough air.‖ The provider auscultates clear breath sounds and notes no signs of increased respiratory effort. Which diagnostic test will the provider perform initially? a. Chest radiograph b. Complete blood count c. Computerized tomography d. Spirometry ANS: B This patient has no signs indicating lung disease, but does exhibit signs of hypoxia. A CBC would evaluate for anemia, which is a more common cause of hypoxia in otherwise healthy adults. Chest radiography is used to evaluate infectious causes. CT is used if interstitial lung disease is suspected. Spirometry is useful to diagnose asthma and COPD.REF: Clinical Presentation/Diagnostics 2. A patient reports shortness of breath with activity and exhibits increased work of breathing with prolonged expirations. Which diagnostic test will the provider order to confirm a diagnosis in this patient? a. Arterial blood gases b. Blood cultures c. Spirometry d. Ventilation/perfusion scan ANS: C The patient has signs of either asthma or COPD. Spirometry is essential to both the diagnosis and management of these diseases. ABGs are useful when evaluating severity of exacerbations, but are not specific to these diseases. Blood cultures are drawn if pneumonia is suspected. A ventilation/perfusion scan is performed to evaluate for pulmonary thromboembolic disease. REF: DiagnosticsTest Bank 2 3. An older patient with COPD is experiencing dyspnea and has an oxygen saturation of 89% on room air. The patient has no history of pulmonary hypertension or congestive heart failure. What will the provider order to help manage this patient’s dyspnea? a. Anxiolytic drugs b. Breathing exercises c. Opioid medications d. Supplemental oxygen ANS: B Formal pulmonary rehabilitation programs, including breathing exercises, are used to manage long-term disease such as COPD. Anxiolytics and opioids must be used cautiously because of respiratory depression side effects. Medicare does not approve oxygen supplementation unless saturations are less than 88% on room air or for patients who have pulmonary hypertension or CHF who have saturations 89%.REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 108: Hemoptysis Test Bank Multiple Choice 1. A patient with hemoptysis and no other symptoms has a normal chest radiograph, CT, and fiberoptic bronchoscopy studies. What is the next action in managing this patient? a. Observation b. Prophylactic antibiotics c. Specialist consultation d. Surgical intervention ANS: A Patients with negative findings on CXR, CT, and bronchoscopy, with no risk factors may be observed for 3 years. Antibiotics are not indicated, since signs of infection are not present. Specialty consultation and surgery are not indicated.REF: Management 2. A patient reports coughing up a small amount of blood after a week of cough and fever. The patient has been previously healthy and does not smoke or work around pollutants or irritants. What will the provider suspect as the most likely cause of this patient’s symptoms? a. Infection b. Lung abscess c. Malignancy d. Thromboembolism ANS: A In a healthy patient without risk factors who has a cough and fever, infection is the most likely cause. Lung abscess may occur, but is less likely. Malignancy is also less likely. Thromboembolism is more likely after surgery or with trauma.REF: Differential Diagnosis 3. A patient with a smoking history of 35 pack years reports having a chronic cough with recent symptoms of pink, frothy blood on a tissue. The chest radiograph shows a possible nodule in the right upper lobe. Which diagnostic test is indicated? a. Coagulation studies b. Computerized tomography c. Fiberoptic bronchoscopy d. Needle biopsyTest Bank 2 ANS: B CT is suggested for initial evaluation of patients at high risk of malignancy, such as a smoker with >30 pack years, who have suspicious findings on chest radiography. Coagulation studies are performed for patients taking anticoagulants or a history of coagulopathy. Fiberoptic bronchoscopy is used with CT, but is not the initial test. Needle biopsy is performed if other tests indicate a tumor.REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 109: Lung Cancer Test Bank Multiple Choice 1. A patient with small cell lung cancer (SCLC) has undergone chemotherapy with a good initial response to therapy. What will the provider tell this patient about the prognosis for treating this disease? a. Surgical resection will improve survival chances. b. That relapse is likely with a poor prognosis. c. There is an 80% chance of 5-year survival. d. Treatment will proceed with curative intent. ANS: B Although SCLC often responds very well initially to chemotherapy, the majority of patients will relapse and the 5-year survival rates are approximately 10%. Surgical resection does not play a significant role in the management of SCLC because the majority of patients have metastatic disease at diagnosis. Treatment is generally palliative.REF: Small Cell Lung Cancer 2. When screening for metastatic cancer in a patient with lung cancer, the provider will assess for Select all that apply. a. complaints of headache. b. increased cough. c. low hematocrit. d. lymph nodes greater than 1 cm. e. unexplained weight gain. ANS: A, C, D Headaches may indicate brain metastases. Low hematocrit and lymphadenopathy with nodes greater than 1 cm also indicate metastasis. Increased cough is a sign of lung cancer itself, not metastasis. Patients with metastatic cancer have unexplained weight loss of more than 10 pounds.REF: Clinical Presentation and Physical Examination 3. A patient with a cough has a suspicious lung lesion, a mediastinal lymph mass, and several bone lesions. What test is indicated to determine histology and staging of this cancer? a. Biopsy of a bone lesionTest Bank 2 b. Bone marrow aspiration and biopsy c. Bronchoscopy with lung biopsy d. Thoracentesis and pleural fluid cytology ANS: A The diagnosis and stage should be determined in the least invasive manner possible. A single biopsy of the bone lesion can determine histology and staging. The other procedures are more invasive and not necessary.REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 110:Pleural Effusions and Pleurisy Test Bank Multiple Choice 1. Which are causes of pleural effusions? Select all that apply. a. Allergies b. Breast cancer c. Bronchiectasis d. Congestive heart failure e. Dehydration ANS: B, C, D Breast cancer, bronchiectasis, and CHF can all cause pleural effusions. Allergies and dehydration do not.REF: Pathophysiology 2. A patient complains of shortness of breath when in a recumbent position and reports coughing and pain associated with inspiration. The provider notes distended neck veins during the exam. What is the likely cause of these findings? a. Congestive heart failure b. Hepatic disease c. Pulmonary embolus d. Pulmonary infection ANS: A CHF causes the symptoms described above, with distended neck veins being a significant finding. Hepatic disease would also cause abdominal distention with ascites and hepatomegaly. Pulmonary embolus has marked shortness of breath. Pulmonary infection causes inflammation and a friction rub.REF: Clinical Presentation/Differential DiagnosisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 111: Pneumonia Test Bank Multiple Choice 1. A patient has a cough and fever and the provider auscultates rales in both lungs that do not clear with cough. The patient reports having a headache and sore throat prior to the onset of coughing. A chest radiograph shows patchy, nonhomogeneous infiltrates. Based on these findings, which organism is the most likely cause of this patient’s pneumonia? a. A virus b. Mycoplasma c. S. pneumoniae d. Tuberculosis ANS: B Atypical pneumonias, such as those caused by mycoplasma often present with headache and sore throat and will have larger areas of infiltrate on chest radiograph. Viral pneumonias show more diffuse radiographic findings. S. pneumonia will have high fever and cough and distinct areas of infiltration.REF: Pathophysiology/Clinical Presentation 2. A young adult, previously healthy clinic patient has symptoms of pneumonia including high fever and cough. Auscultation reveals rales in the left lower lobe. A chest radiograph is normal. The patient is unable to expectorate sputum. Which treatment is recommended for this patient? a. A B-lactam antibiotic plus a fluoroquinolone b. A respiratory fluoroquinolone antibiotic c. Empiric treatment with a macrolide antibiotic d. Hospitalization for intravenous antibiotics ANS: C This patient likely has community-acquired pneumonia. The patient has typical symptoms and, even though the chest radiograph is normal, will require outpatient treatment. For communityacquired pneumonia in a previously healthy individual, treatment with a macrolide antibiotic is the recommended first-line therapy. B-lactam plus fluoroquinolone therapy is used for patients in the ICU. Respiratory fluoroquinolones are used for patients with underlying disorders who develop pneumonia. Hospitalization is not necessary.REF: ManagementTest Bank 2 3. A patient who was initially treated as an outpatient for pneumonia and then hospitalized for two weeks after no improvement continues to show no improvement after several antibiotic regimens have been attempted. What is the next step in managing this patient? a. Administration of the pneumonia vaccine b. Increasing the dose of the antibiotics c. Open lung biopsy d. Performing diagnostic bronchoscopy ANS: D Patients who do not respond to antibiotic therapy may have opportunistic fungal or other infections, bronchogenic carcinoma, or other diseases. Bronchoscopy can exclude or confirm these. The pneumonia vaccine is preventative for pneumococcal causes and will not help this patient. Increasing the dose of the antibiotics is not recommended. Open lung biopsy may be performed if a bronchoscopy is inconclusive.REF: ComplicationsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 112:Pneumothorax Test Bank Multiple Choice 1. A patient who has a central line develops respiratory compromise. What is the initial intervention for this patient? a. Lung ultrasonography to determine the cause b. Obtaining cultures and starting antibiotics c. Prompt removal of the central line d. Rapid assessment and resuscitation ANS: D Patients with central lines are at increased risk for pneumothorax. Acute respiratory distress is a medical emergency and assessment and resuscitation should begin immediately. Lung US, cultures and antibiotics, and removal of the central line may be performed if indicated when the patient is stabilized.REF: Physical Examination 2. Which method of treatment is used for traumatic pneumothorax? a. Needle aspiration of the pneumothorax b. Observation for spontaneous resolution c. Placement of a small-bore catheter d. Tube thoracostomy ANS: D Traumatic pneumothorax requires tube thoracostomy because of its ability to drain larger volumes of air along with blood and fluids. Needle aspiration is safe for primary pneumothorax. Observation for spontaneous resolution is indicated for small pneumothoraxes.REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 113: Pulmonary Embolism Test Bank Multiple Choice 1. Which clinical sign is especially worrisome in a patient with a pulmonary embolism? a. Abnormal lung sounds b. Dyspnea c. Hypotension d. Tachycardia ANS: C Hypotension in a patient with PE has a high correlation with acute right ventricular failure and subsequent death. The other signs are common with PE.REF: Diagnosis 2. A patient who has undergone surgical immobilization for a femur fracture reports dyspnea and chest pain associated with inspiration. The patient has a heart rate of 120 beats per minute. Which diagnostic test will confirm the presence of a pulmonary embolism? a. Arterial blood gases b. CT angiography c. D-dimer d. Electrocardiogram ANS: B Ct angiography is used to diagnose PE. D-dimer assays have good negative predictive value but have poor positive predictive value, making it useful for excluding but not confirming the presence of PE. An ECG does not confirm PE but is used to demonstrate comorbid conditions. Arterial blood gases do not confirm PE and are used to identify the degree of respiratory compromise.REF: Diagnostics 3. A patient develops a pulmonary embolism after surgery and shows signs of right-sided heart failure. Which drug will be administered to this patient? a. Low molecular heparin b. Tissue plasminogen activator c. Unfractionated heparin d. WarfarinTest Bank 2 ANS: B Fibrinolytic therapy with recombinant tissue plasminogen activator is given to patients with hypotension and right-sided heart failure. Heparin is used for its anticoagulant properties in all patients with PE. Warfarin is not indicated.REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 114: Pulmonary Hypertension Test Bank Multiple Choice 1. A patient with increased left-sided heart pressure will have which type of pulmonary hypertension? a. Group 2 b. Group 3 c. Group 4 d. Group 5 ANS: A Group 2 pulmonary hypertension is associated with increased left-sided heart pressure.REF: Definition and Epidemiology 2. A patient who has had mild pulmonary hypertension with a previous symptom of a loud second heart sound on exam now has edema and jugular vein distension. This indicates which complication? a. Left ventricular dysfunction b. Right ventricular dysfunction c. Tricuspid valve involvement d. Mitral valve involvement ANS: B Right ventricular dysfunction occurs as the disease worsens with manifestations that include jugular vein distension, edema, and increased liver size. These symptoms do not indicate left ventricular dysfunction or valvular involvement.REF: Physical Examination 3. A patient with pulmonary arterial hypertension (PAH) has increased dyspnea with activity. Which drug may be prescribed to manage this on an outpatient basis? a. An inhaled prostanoid b. Bosentan c. Epoprostenol d. Trepostinil ANS: BTest Bank 2 Bosentan helps promote pulmonary artery smooth muscle cell proliferation and improves exercise capacity. It is also given PO, so is easy to give on an outpatient basis. Inhaled prostanoids have a short half-life and must be given 6 to 9 times daily. Epoprostenol has a short half-life and must be given IV. Trepostinil is given IV.REF: Management/Table 114—1: Therapies for Pulmonary Arterial HypertensionButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 115: Sarcoidosis Test Bank Multiple Choice 1. A patient who has dyspnea and chest pain along with occasional chills and night sweats has a chest radiograph that shows bilateral hilar lymphadenopathy and pulmonary infiltrates. The provider suspects which classification of sarcoidosis? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 ANS: B Stage 1 sarcoidosis is classified based on bilateral hilar lymphadenopathy (BHL) only. Stage 2 presents with BHL and pulmonary infiltrates, Stage 3 with pulmonary infiltrates without BHL, and stage 4 with pulmonary fibrosis.REF: Diagnostics 2. A patient with stage 1 sarcoidosis who is taking a nonsteroidal anti-inflammatory medication to treat joint discomfort develops mild dyspnea and cough. Which medication will be added to treat this symptom? a. A beta-adrenergic medication b. An antimalarial agent c. An immunosuppressant drug d. An oral corticosteroid ANS: D Corticosteroids are begun when pulmonary symptoms develop. Beta-adrenergics are not used. Antimalarial agents are used to treat chronic skin lesions. Immunosuppressants are used when corticosteroids are no longer effective or when the disease progresses.REF: Management 3. When following a patient with sarcoidosis over time, which diagnostic test is useful to help monitor the progression of the disease? a. Chest radiographs b. Erythrocyte sedimentation rate c. Pulmonary function test d. Radionucleotide scanningTest Bank 2 ANS: C Pulmonary function tests may be normal or may demonstrate a restrictive pattern and may be of most value in monitoring the course of the disease in individual cases. Chest radiographs may help with staging the disease initially. The ESR may be elevated with sarcoidosis, but is a nonspecific finding. Radionucleotide scanning is non-specific, although it can be used to locate the presence of pulmonary lesions.REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 116: Cardiac Diagnostic Testing: Noninvasive Assessment of Coronary Artery Disease Test Bank Multiple Choice 1. An asymptomatic 63-year-old female has a low-density lipoprotein level of 135 mg/dL. Which test is beneficial to assess this patient’s coronary artery disease risk? a. Coronary artery calcium score b. C-reactive protein c. Exercise echocardiography d. Myocardial perfusion imaging ANS: B The CRP is useful in asymptomatic women >60 years who have LDL <160 mg/dL to predict CAD risk. Although the CACS has shown some benefit in patients with moderate risk, the role for this diagnostic test is unclear. Exercise echocardiography and myocardial perfusion imaging are not performed initially.REF: Overview of Cardiac Diagnostic Testing 2. Which risk assessment for coronary artery disease is recommended for all female patients? a. Coronary artery calcium score b. Electrocardiogram c. Exercise stress test d. Framingham risk score ANS: D The Framingham risk score is a quick method for identifying potential risk for CAD and can guide providers in choosing subsequent tests based on risk level. The ECG is performed on women with risk factors. The exercise stress test is useful in symptomatic women who have a normal ECG. The CACS may be used if moderate risk is present.REF: Diagnostic Testing for Cardiovascular Disease in WomenButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 117: Abdominal Aortic Aneurysm Test Bank Multiple Choice 1. A patient reports abdominal and back pain with anorexia and nausea. During an exam, the provider notes a pulsatile abdominal mass. What is the initial action? a. Immediate referral to a thoracic surgeon b. Ordering computerized tomography angiography c. Scheduling an MRI to evaluate for aortic disease d. Ultrasound of the mass to determine size ANS: D This patient has symptoms consistent with an aortic aneurysm. The initial step is to determine the size of the aneurysm; this can be done by US. Immediate referral is not necessary. MRI and CT diagnostic tests are ordered before surgery to evaluate the characteristics of the aneurysm.REF: Pathophysiology 2. A 70-year-old male patient has an aortic aneurysm measuring 5.0 cm. The patient has poorlycontrolled hypertension, and decompensated heart failure. What is the recommendation for treatment for this patient? a. Endovascular stent grafting of the aneurysm b. Immediate open surgical repair of the aneurysm c. No intervention is necessary for this patient d. Serial ultrasonographic surveillance of the aneurysm ANS: D This patient’s aneurysm is less than 5.5 cm and repair is not necessary at this time. Serial US surveillance is necessary to continue to evaluate size. Repair is risky in patients with hypertension and heart failure, so avoiding procedures if possible is recommended.REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 118: Cardiac Arrhythmias Test Bank Multiple Choice 1. A patient reports sustained, irregular heart palpitations. What is the most likely cause of these symptoms? a. Anemia b. Atrial fibrillation c. Extrasystole d. Paroxysmal attacks ANS: B Atrial fibrillation causes palpitations that are irregular and tend to be sustained. Anemia will cause rapid palpitations that are regular. Extrasystole causes palpitations or an awareness of isolated extra beats with a pause. Paroxysmal attacks start and terminate abruptly and are usually rapid and regular.REF: Tachyarrhythmias 2. An adult patient reports frequent episodes of syncope and lightheadedness. The provider notes a heart rate of 70 beats per minutes. What will the provider do next? a. Evaluate the patient’s orthostatic vital signs b. Monitor the patient’s heart rate while the patient is bearing down c. Order an electrocardiogram and exercise stress test d. Reassure the patient that the symptoms are non-cardiac in origin ANS: A Orthostatic vital signs are helpful to exclude orthostatic hypotension as a cause of syncope and is easily performed in the clinic. Assessment for vagal bradycardia may be performed next. ECG and ETT are not recommended as an initial evaluation in a healthy patient, unless other causes are not determined. Without assessment of the cause of the syncope, cardiac causes cannot be excluded.REF: Physical Examination 3. A child with a history of asthma is brought to the clinic with a rapid heart rate. A cardiac monitor shows a heart rate of 225 beats per minute. The provider notifies transport to take the child to the emergency department. What initial intervention may be attempted in the clinic? a. Administration of intravenous adenosine b. Giving a beta blockerTest Bank 2 c. Providing a loading dose of digoxin d. Using a vagal maneuver or carotid massage ANS: D This child has paroxysmal supraventricular tachycardia. Vagal maneuvers or carotid massage may be attempted to slow the ventricular rate. Adenosine is contraindicated in patients with asthma. Medications such as beta blockers and digoxin are not used in emergency treatment of PSVT.REF: Paroxysmal Supraventricular TachycardiaButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 119: Carotid Artery Disease Test Bank Multiple Choice 1. According to current research, which are associated with a decreased incidence of stroke? a. ≧7 servings of fruits and vegetables per day b. B-complex vitamin supplements c. Intensive insulin therapy in type 1 diabetes d. Low-sugar soda e. Mediterranean diet ANS: A, C, E Individuals without hypertension in Sweden who consumed ≧7 servings of fruits and vegetables per day had a 19% lower risk of stroke than those consuming only one serving per day. Intensive insulin therapy in patients with type 1 diabetes was shown to lower the risk of stroke. Consuming a Mediterranean diet is associated with a reduced stroke risk. B-complex vitamins and low-sugar soda have not shown a decreased risk.REF: Definition and Epidemiology 2. During a routine health maintenance examination, the provider auscultates a cervical bruit. The patient denies syncope, weakness, or headache. What will the provider do, based on this finding? a. Ordera carotid duplex ultrasound b. Order catheter-based angiography c. Refer the patient to a neurosurgeon d. Schedule a computed tomography angiography ANS: A Carotid duplex ultrasound is the primary diagnostic tool for carotid stenosis. A cervical bruit in an asymptomatic patient is an indication for this test. Catheter-based angiography is the criterionbased standard, but has inherent costs and risks. A neurosurgery referral is not indicated without further testing. CTA is used instead of duplex US if the test is not available, if US results are inconclusive, or further evaluation is needed based on US results.REF: DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 120: Chest Pain and Coronary Artery Disease Test Bank Multiple Choice 1. A patient reports recurrent chest pain that occurs regardless of activity and is not relieved by rest. The provider administers a nitroglycerin tablet which does not relieve the discomfort. What is the next action? a. Administer a second nitroglycerin tablet b. Give the patient a beta blocker medication c. Prescribe a calcium channel blocker mediation d. Start aspirin therapy and refer the patient to a cardiologist ANS: B Patient with these symptoms who do not respond to nitroglycerin is likely to have microvascular angina. Treatment is effective with beta blockers. These symptoms are not characteristic of acute MI, so aspirin is not given. A second nitroglycerin tablet is used for classic angina. Calcium channel blockers are not indicated.REF: Microvascular Angina 2. A patient is brought to an emergency department with symptoms of acute ST-segment elevation MI (STEMI). The nearest hospital that can perform percutaneous coronary intervention (PCI) is 3 hours away. What is the initial treatment for this patient? a. Administer heparin b. Give the patient an oral beta blocker c. Initiate fibrinolytic treatment d. Transfer to the PCI-capable institution ANS: C Fibrinolytic therapy should be administered to any patient with evolving STEMI within 30 minutes of the time of first medical contact. Patients more than 120 minutes away from a PCIcapable hospital should be given fibrinolytic therapy since PCI should be performed within 90 minutes if possible. Giving heparin or beta blockers is not helpful.REF: Acute St-Segment Elevation Myocardial Infarction 3. Patients who meet the criteria for statin therapy to help prevent atherosclerotic cardiovascular disease are those with a history of a. a 10 year risk score of 5% and an LDL of 165 mg/dL.Test Bank 2 b. a 10 year risk score of 8% with an LDL of 80 mg/dL. c. a low-density lipoprotein (LDL) level >190 mg/dL. d. diabetes and an LDL between 40 and 70 mg/dL. e. previous myocardial infarction. ANS: B, C, E Patients with previous MI, those with risk scores >8% and an LDL >70 mg/dL, and those with LDL levels >190 mg/dL are candidates for statin therapy. Patients with a risk score <7.5% with LDL levels between 75 and 190 mg/dL are not candidates and patients who have diabetes with LDL levels <75 mg/dL are not candidates.REF: Lipid GuidelinesButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 121: Heart Failure Test Bank Multiple Choice 1. A patient who has heart failure with reduced ejection fraction will have which symptoms? a. Dyspnea and fatigue without volume overload b. Impairment of ventricular filling and relaxation c. Mild, exertionally related dyspnea d. Pump failure from left ventricular systolic dysfunction ANS: D Heart failure with reduced ejection fraction results in pump failure from ventricular systolic dysfunction. Heart failure with preserved ejection fraction may have milder symptoms and is associated with impairment of ventricular filling and relaxation.REF: Definition and Epidemiology 2. A patient who has been diagnosed with heart failure for over a year reports being comfortable while at rest and experiences palpitations and dyspnea when walking to the bathroom. Which classification of heart failure is appropriate based on these symptoms? a. Class I b. Class II c. Class III d. Class IV ANS: B Patients with Class II heart failure (HF) will have slight limitation of activity and will be comfortable at rest with symptoms occurring with ordinary physical activity. Patients with Class I HF do not have limitations and ordinary physical activity does not produce symptoms. With Class III HF, less than usual activity will produce symptoms. With Class IV HF, symptoms are present even at rest and all physical activity worsens symptoms.REF: Table 121-7: Classification of Heart Failure 3. A patient who has Class II heart failure is taking an ACE inhibitor and reports a recurrent cough that does not interfere with sleep or activity. What will the provider do initially to manage this patient? a. Assess serum potassium and sodium immediatelyTest Bank 2 b. Discontinue the ACE inhibitor and prescribe an ARB c. Provide reassurance that this is a benign side effect d. Withhold the drug and evaluate renal and pulmonary function ANS: C Cough occurs in about 20% of patients who take ACE inhibitors and is not dangerous. The patient should be reassured that this is the case. If the cough is annoying, alternate therapy with an ARB may be considered. It is not necessary to evaluate electrolytes, renal function, or pulmonary function.REF: Pharmacologic Therapy Overview/ACE InhibitorsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 122: Hypertension Test Bank Multiple Choice 1. Which are causes of secondary hypertension? a. Increased salt intake b. Isometric exercises c. Nonsteroidal anti-inflammatory drugs d. Oral contraceptives e. Sleep apnea ANS: C, D, E NSAIDs and OCPs can both increase the risk of hypertension. Sleep apnea causes secondary hypertension. Increased salt intake does not cause HTN, but those with HTN are more sensitive to sale. Regular isometric exercise can decrease blood pressure. REF: Primary Hypertension/Secondary Hypertension 2. A 55-year-old patient has a blood pressure of 138/85 on three occasions. The patient denies headaches, palpitations, snoring, muscle weakness, and nocturia and does not take any medications. What will the provider do next to evaluate this patient? a. Assess serum cortisol levels b. Continue to monitor blood pressure at each health maintenance visit c. Orderurinalysis, CBC, BUN, and creatinine d. Refer to a specialist for a sleep study ANS: C This patient has pre-hypertension levels and should be evaluated. UA, CBC, BUN, and creatinine help to evaluate renal function and are in the initial workup. Serum cortisol levels are performed if pheochromocytoma is suspected, which would cause headache. The patient does not have snoring, so a sleep study is not indicated at this time. It is not correct to continue to monitor without assessing possible causes of early hypertension. REF: Differential Diagnosis/Diagnostics 3. An African-American patient who is being treated with a thiazide diuretic for chronic hypertension reports blurred vision and shortness of breath. The provider notes a blood pressure of 185/115. What is the recommended action for this patient?Test Bank 2 a. Add a beta blocker to the patient’s regimen b. Admit to the hospital for evaluation and treatment c. Increase the dose of the thiazide medication d. Prescribe a calcium channel blocker ANS: B Patients with a blood pressure >180/120 or those with signs of target organ symptoms should be admitted to inpatient treatment with specialist consultation. Changing the medications may be done with consultation, but a hospitalization and stabilization must be done initially. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 123: Infective Endocarditis Test Bank Multiple Choice 1. A patient has infective endocarditis and is being treated with empiric antibiotics after blood cultures are inconclusive. The patient develops a severe headache along with transient neurologic changes. What is the likely cause of these symptoms? a. Extra-cardiac abscess formation b. Haemophilus infection c. Mycotic aneurysm d. Rheumatic heart fever ANS: C Patients with mycotic aneurysms will present with symptoms of severe unrelenting headache, neurological changes, and signs of cranial nerve involvement. Extracardiac abscess formation depends on the organ involved. Haemophilus infections cause larger vegetations in the heart. Rheumatic heart fever has a classic group of symptoms involving the skin. REF: Clinical Presentation and Physical Examination/Neuro logic Findings 2. A patient has native valve endocarditis. While blood cultures are pending, which antibiotics will be ordered as empiric treatment? a. A beta-lactamase resistant penicillin and an antifungal drug b. Imipenem-cilastin and ampicillin c. Penicillin and an aminoglycoside antibiotic d. Vancomycin and quinupristin-dalfopristin ANS: C The most common organism in NVE is S. aureus; until resistance is known, treatment with penicillin and an aminoglycoside is needed, although most strains causing NVE are not penicillin-resistant. Antifungal infections are rare and antifungal medications are not part of empiric therapy. Imipenem-cilcastin plus ampicillin is given for identified Enterococcus faecalis infection. Vancomycin and quinupristin-dalfopristin is used, with limited evidence for benefit, for Enterococcus faecium infection. REF: Management/Table 123-1: Some Suggested Antibiotic Regimens 3. A patient who is on renal dialysis is diagnosed with infective endocarditis. What causative organisms are more likely in this patient?Test Bank 2 a. Enterococcal organisms b. Neisseria gonorrhea c. Pseudomonas aeruginosa d. Staphylococcus aureus ANS: D This patient is more likely to have a health care associated endocarditis; most of these are caused by S. aureus. Enterococcal organisms are the second highest cause in this population. REF: Health Care-Associated EndocarditisButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 124: Myocarditis Test Bank Multiple Choice 1. A patient who is a runner is diagnosed with viral myocarditis and asks when he may begin exercising again. What will the provider tell this patient? a. Exercise is contraindicated for life b. Exercise may resume when symptoms subside c. He may resume exercise in 6 months d. He must be symptom-free for 1 year ANS: C Patients with myocarditis should not exercise for 6 months after the onset of symptoms. REF: Management 2. Which test is diagnostic for diagnosing myocarditis? a. Echocardiogram b. Electrocardiogram c. Endomyocardial biopsy d. Magnetic resonance imaging ANS: C Endomyocardial biopsy is the only definitive test to diagnose myocarditis. Other tests are useful in determining symptoms, but are not specific to this diagnosis. REF: Diagnostics 3. A previously healthy patient develops myocarditis and presents with sudden onset of dyspnea, fatigue, and orthopnea. A family history is negative. The provider suspects myocarditis. What is the most likely etiology for this patient? a. Autoimmune disorder b. Bacterial infection c. Protozoal infection d. Viral infection ANS: DTest Bank 2 Viral infection is the most common cause of myocarditis. Other infections are less likely. Although this patient may have an autoimmune disorder, the absence of family history makes this somewhat less likely. REF: PathophysiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 125: Peripheral Arterial and Venous Insufficiency Test Bank Multiple Choice 1. An elderly female without prior history of cardiovascular disease reports lower leg soreness and fatigue when shopping or walking in the neighborhood. The primary care provider notes decreased pedal pulses bilaterally. Which test will the provider order initially to evaluate for peripheral arterial disease based on these symptoms? a. Digital subtraction angiography b. Doppler ankle, arm index c. Magnetic resonance angiography d. Segmental limb pressure measurement ANS: B The Doppler study may be performed easily to indicate the likelihood of PAD. Other tests are performed only if indicated. REF: Diagnostics 2. A 75-year-old patient reports pain and a feeling of tiredness in both legs that only relieves after sitting for 30 minutes or more. What the does provider suspect as the cause for these symptoms? a. Buerger’s disease b. Cauda equina syndrome c. Diabetic neuropathy d. Peripheral arterial disease ANS: B Patients with cauda equina syndrome, which causes spinal stenosis, will often not get relief until they sit down for a period of time. Buerger’s disease involves both the upper and lower extremities. Diabetic neuropathy may mask pain. PAD involves these symptoms that stop with rest. REF: Differential Diagnosis 3. A patient is diagnosed with PAD and elects not to have angioplasty after an angiogram reveals partial obstruction in lower extremity arteries. What will the provider recommend to help with relief of symptoms in this patient? a. Daily aspirin therapy to prevent clotting b. Statin therapy with clopidogrelTest Bank 2 c. Walking slowly for 15 to 20 minutes twice daily d. Walking to the point of pain each day ANS: D Studies have demonstrated that an exercise program involving walking to the point of pain is as effective as angioplasty. Medications are useful to prevent progression of plaque formation and to prevent MI. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 126: Valvular Heart Disease and Cardiac Murmurs Test Bank Multiple Choice 1. Which are factors can cause a heart murmur? a. Backward flow through a septal defect b. Backward flow into a normal vessel c. Forward flow into a dilated vessel d. High rates of flow through a normal valve e. Low rates of flow into a cardiac chamber ANS: A, C, D High rates of flow into either normal or abnormal vessels can cause murmurs. Backward flow into septal defects, regurgitant valves, or PDAs can cause murmurs. Forward flow into constricted or irregular valves or into a dilated vessel can cause murmur. Backward flow into a normal vessel or low flow rates are not responsible for murmurs. REF: Definition 2. A young female patient has known mitral valve prolapse. During a routine health maintenance exam, the provider notes an apical systolic murmur and a midsystolic click on auscultation. The patient denies chest pain, syncope, or palpitations. What will the provider do? a. Admit the patient to the hospital for evaluation and treatment b. Consult with the cardiologist to determine appropriate diagnostic tests c. Continue to monitor the patient every 3 years d. Reassure the patient that these findings are expected ANS: B Most patients with mitral valve prolapse are monitored every 3 years unless they have a systolic murmur. The provider should consult with the cardiologist. Hospital admission is not necessary since the patient is asymptomatic. REF: Mitral Valve Prolapse 3. A patient has a cardiac murmur that peaks in midsystole and is best heard along the left sternal border. The provider determines that the murmur decreases in intensity when the patient changes from standing to squatting and increases in intensity with the Valsalva maneuver. Which cause will the provider suspect for this murmur? a. Aortic stenosisTest Bank 2 b. Hypertrophic cardiomyopathy c. Mitral valve prolapse d. Tricuspid regurgitation ANS: B These findings occur with hypertrophic cardiomyopathy. With aortic stenosis, the murmur is a harsh crescendo-decrescendo heard best at the right sternal border that decreases in intensity with the Valsalva maneuver. With mitral valve prolapse, the murmur is heard in mid- to late systole, is heard best at the left lower sternal border, and may have a click that moves to later systole or disappear with the Valsalva maneuver. With tricuspid regurgitation, the murmur may occur at early, mid, or late systole, is heard at the left lower sternal border, and decreases with the Valsalva maneuver. REF: Table 126-1: MurmursButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 127:Abdominal Pain and Infections Test Bank Multiple Choice 1. A patient is in clinic for evaluation of sudden onset of abdominal pain. The provider palpates a pulsatile, painful mass between the xiphoid process and the umbilicus. What is the initial action? a. Ordera CBC, type and crossmatch, electrolytes, and renal function tests b. Perform an ultrasound examination to evaluate the cause c. Schedule the patient for an aortic angiogram d. Transfer the patient to the emergency department for a surgical consult ANS: D This patient has symptoms and physical findings consistent with a ruptured aortic aneurysm and should have an immediate surgical consult. Ordering other tests is not necessary by the primary provider. REF: Ruptured Aortic Aneurysm 2. Which symptoms in a patient with abdominal pain are suggestive of appendicitis? a. Abdominal rigidity along with pain b. Pain accompanied by low-grade fever c. Pain occurring prior to nausea and vomiting d. Pain that begins in the left lower quadrant e. Prolonged duration of right lower quadrant pain ANS: A, B, C Patients with appendicitis typically have pain that begins in the epigastric or periumbilical area and migrates to the left lower quadrant. Abdominal rigidity is common, as is low-grade fever. Pain precedes other symptoms and when the symptoms occur in any other order, the diagnosis of appendicitis should be questioned. Pain is usually of short duration. REF: Appendicitis/Clinical Presentation 3. An adult patient has intermittent, crampy abdominal pain with vomiting. The provider notes marked abdominal distention and hyperactive bowel sounds. What will the provider do initially? a. Admit the patient to the hospital for consultation with a surgeon b. Obtain upright and supine radiologic views of the abdomenTest Bank 2 c. Prescribe an antiemetic and recommend a clear liquid diet for 24 hours d. Schedule the patient for a barium swallow and enema ANS: B If available, the primary care provider can order radiographic studies of the abdomen and chest. Once small bowel obstruction is confirmed or suspected, immediate hospitalization with surgeon referral is necessary. Because small bowel obstruction can have potentially serious or lifethreatening consequences, waiting 24 hours is not recommended. REF: Small Bowel Obstruction/Clinical Presentation/DiagnosticsButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 128: Anorectal Complaints Test Bank Multiple Choice 1. What are recommendations for patients with chronic pruritis ani? a. Application of a topical antihistamine b. Applying a of 1% hydrocortisone cream for several months c. Avoid tight-fitting or non-breathable clothing d. Avoiding perfumed soaps and toilet papers e. Using a hair dryer on the coolsetting to control itching ANS: C, D, E Measures to control itching include avoiding tight-fitting clothing as well as perfumed products and keeping the area clean and dry and using a cool hair dryer to dry the skin. Topical antihistamines are not used. Using a topical steroid longer than 2 weeks causes thinning of the skin. REF: Pruritis Ani/Management 2. A patient reports anal pruritis and occasional bleeding with defecation. An examination of the perianal area reveals external hemorrhoids around the anal orifice as the patient is bearing down. The provider orders a colonoscopy to further evaluate this patient. What is the treatment for this patient’s symptoms? a. A high-fiber diet and increased fluid intake b. Daily laxatives to prevent straining with stools c. Infiltration of a local anesthetic into the hemorrhoid d. Referral for possible surgical intervention ANS: A Most hemorrhoids, unless incarcerated or painful, are treated conservatively. A high-fiber diet and increased fluid intake are recommended first. Daily laxatives are not recommended because the variation in stool consistency makes hemorrhoid management more difficult. Infiltration of a local anesthetic is performed for thrombosed external hemorrhoid prior to removing the clot. Hemorrhoidectomy is performed for severe or very painful hemorrhoids. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 129: Cholelithiasis and Cholecystitis Test Bank Multiple Choice 1. A patient has sudden onset of right upper quadrant and epigastric abdominal pain with fever, nausea, and vomiting. The emergency department provider notes yellowing of the sclerae. What is the probable cause of these findings? a. Acute acalculous cholecystitis b. Chronic cholelithiasis c. Common bile duct obstruction d. Infectious cholecystitis ANS: C This patient has symptoms of cholecystitis with bile duct obstruction, which causes jaundice. The common triad of RUQ pain, fever, and jaundice occurs when a stone in lodged in the common bile duct. Acute acalculous cholecystitis is inflammation without stones. Chronic cholelithiasis doesn’t cause acute symptoms; jaundice occurs with obstruction. Infectious cholecystitis may occur without obstruction. REF: Clinical Presentation 2. A patient with a previous history of liver disease has bile duct obstruction. Which procedure will be used for this patient? a. Chemical dissolution of the gallstone b. Lithotripsy c. Open cholecystectomy d. Laparoscopic cholecystectomy ANS: C Patients with possible liver disease should have open cholecystectomy. The other procedures are contraindicated. Chemical dissolution is not reliable and may take some time. REF: Management 3. A 30-year-old woman has right upper quadrant abdominal pain, nausea, and vomiting. Which diagnostic test will the provider order? a. Abdominal CT with contrast b. Abdominal ultrasound c. MRI of the abdomen d. Plain abdominal radiographsTest Bank 2 ANS: B Women of childbearing age may safely have ultrasound. Until pregnancy is ruled out, the other studies may be harmful to a developing fetus and should be avoided. REF: Diagnostics 4. A patient has fever, nausea, vomiting, anorexia, and right upper quadrant abdominal pain. An ultrasound is negative for gallstones. Which action is necessary to treat this patient’s symptoms? a. Empiric treatment with antibiotics b. Hospitalization for emergent treatment c. Prescribing ursodeoxycholic acid d. Supportive care with close follow-up ANS: B This patient has symptoms of acute acalculous cholecystitis, and is critically ill. Hospitalization is required. Empiric treatment with antibiotics and supportive care with follow-up do not address critical care needs. Ursodeoxycholic acid is a medication that helps with gallstone dissolution; this patient does not have gallstones. REF: Clinical Presentation/Physical ExaminationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 130: Cirrhosis Test Bank Multiple Choice 1. A patient who is a chronic alcoholic reports weight loss, pruritis, and fatigue and the provider suspects cirrhosis of the liver. The patient’s urine and stools appear normal. What do these findings indicate? a. Early liver cirrhosis b. Late liver cirrhosis c. Liver failure and ascites d. Probably viral hepatitis ANS: A Early symptoms of cirrhosis are characterized by this patient’s symptoms. As the condition worsens, stools and urine change color and the patient develops anorexia, nausea, and vomiting. Liver failure and ascites are late and will include abdominal pain. Viral hepatitis is a less likely diagnosis in the patient with a history of alcoholism. REF: Clinical Presentation 2. A patient with cirrhosis develops ascites. Which medication will be ordered initially to improve symptoms? a. Cephalosporin b. Furosemide c. Lactulose d. Spironolactone ANS: D Spironolactone is the initial diuretic used to improve fluid diuresis in patients with ascites. Furosemide may be used as adjunctive therapy. Cephalosporin is used when infections occurs. Lactulose is used to increase stools and reduce encephalopathy. REF: Management 3. A patient has fibrotic liver disease and a liver biopsy shows micronodular cirrhosis. What is the most common cause of this form of cirrhosis? a. Alcoholism b. Hepatitis C c. Hepatocellular carcinoma d. Right-sided heart failureTest Bank 2 ANS: A Micronodular cirrhosis is often associated with alcoholic liver disease. Viral causes and carcinoma usually cause macronodular cirrhosis. Right-sided heart failure occurs with many other causes as part of the disease development. REF: Definition and EpidemiologyButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 131: Constipation Test Bank Multiple Choice 1. A patient is diagnosed with chronic constipation who uses polyethylene glycol, reports increased abdominal discomfort with nausea and vomiting. What is the initial action by the provider? a. Increase the dose of polyethylene glycol b. Obtain radiographic abdominal studies c. Perform a stool culture and occult blood d. Refer to a specialist for colonoscopy ANS: B Patients with abdominal pain, nausea, and vomiting should have radiologic studies to exclude obstruction, ileus, megacolon, or volvulus. If those are ruled out, increasing the laxative may be warranted. Stool culture is indicated if the parasite ascariasis is suspected. Referral for colonoscopy is needed if alarm symptoms for neoplasm are present. REF: Diagnostics 2. A patient reports a decrease in the frequency of stools and asks about treatment for constipation. Which findings are part ofthe Rome III criteria for diagnosing constipation? a. Feeling of incomplete evacuation b. Fewer than 5 stools per week c. Lumpy stools d. Presence of irritable bowel syndrome e. Symptoms present for 3 months ANS: A, C, E According to the Rome III criteria, symptoms must have begun 6 months prior and persisted for at least 3 months and include a feeling of incomplete evacuation, lumpy or hard stools, fewer than 3 stools per week, and not meeting criteria for irritable bowel syndrome. REF: Definition and Epidemiology 3. A patient has recurrent constipation which improves with laxative use but returns when laxatives are discontinued. Which pharmacologic treatment will the provider recommend for long-term management? a. BisacodylTest Bank 2 b. Docusate sodium c. Methylcellulose d. Mineral oil ANS: C Methylcellulose is a bulk-forming product and is used initially. The other medications are used for more severe constipation and not recommended for long-term use. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 132:Diarrhea, Noninfectious Test Bank Multiple Choice 1. Which types of chronic noninfectious diarrhea will cause fatty stools? a. Celiac disease b. Cystic fibrosis c. Diabetes mellitus d. Lactose intolerance e. Pancreatic insufficiency ANS: A, B, E Celiac disease, cystic fibrosis, and pancreatic insufficiency all produce malabsorption of fats and will result in fatty stools. Diabetes results in glucose malabsorption, while lactose intolerance causes lactose malabsorption. REF: Differential Diagnosis/Chronic Noninfectious Diarrhea 2. A patient develops acute diarrhea and then comes to clinic two weeks later reporting profuse watery, bloody diarrheal stools 6 to 8 times daily. The provider notes a toxic appearance with moderate dehydration. Which test is indicated to diagnose this cause? a. Qualitative and quantitative fecal fat b. Stool collection for 24-hour stool pH c. Stool sample for C. difficile toxin d. Wright stain of stool for white blood cells ANS: C Patients with acute onset diarrhea lasting more than 2 weeks with profuse, watery, bloody stools of more than 6 times in a 24-hour period warrants testing for C. difficile toxin. Qualitative and quantitative fecal fat, 24-hour pH studies, and Wright stain for WBCs are performed when chronic diarrhea are present. REF: Diagnostics/Acute Diarrhea/Chronic Diarrhea 3. A patient who developed chronic diarrhea after gastric surgery asks what can be done to mitigate symptoms. What will the provider recommend initially? a. A diet high in carbohydrates b. Avoiding liquids with meals c. Empiric antibiotic therapy d. Probiotic supplementsTest Bank 2 ANS: B Initial suggestions for treating postoperative diarrhea will include avoiding fluids during meals and lying down after meals. Concentrated carbohydrates may trigger symptoms. Empiric antibiotic therapy is indicated for small intestinal bacterial overgrowth syndrome with specific symptoms and an association with an elevated folate level. Probiotic supplements may be used as adjunctive therapy. REF: ManagementButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 133: Diverticular Disease Test Bank Multiple Choice 1. A patient has intermittent left-sided lower abdominal pain and fever associated with bloating and constipation alternating with diarrhea. The provider suspects acute diverticulitis. Which tests will the provider order? a. Barium enema examination b. CT scan of abdomen and pelvis c. Plain abdominal radiographs d. Rigid sigmoidoscopy e. Stool for occult blood ANS: B, E A CT scan of the abdomen and pelvis is the preferred imaging study if acute diverticulitis is suspected with diverticular abscess. Occult blood tests are necessary because uncomplicated diverticulosis is not known to cause occult rectal bleeding. Barium enema should be avoided in acute diverticulitis because of the risk of extravasation of barium into the peritoneal cavity, causing chemical peritonitis. Plain radiographs are not useful because they will appear normal. Rigid sigmoidoscopy usually cannot be performed beyond the recto-sigmoid junction, so is not useful. REF: Diagnostics 2. A patient has a history of diverticular disease and asks what can be done to minimize acute symptoms. What will the practitioner recommend to this patient? a. Avoiding saturated fats and red meat b. Consuming a diet high in fiber c. Taking an anticholinergic medication d. Using bran to replace high-fiber foods ANS: B Increasing dietary fiber reduces constipation and reduces the incidence of acute symptoms. Avoiding saturated fats and red meats does not reduce the risk of diverticulitis, but does decrease the risk of colon cancer. Anticholinergics and antispasmodics do not prevent attacks, but may help with symptoms. Bran may be used as an adjunct to high-fiber foods, but should not replace other high-fiber sources. REF: ManagementTest Bank 2 3. A patient who has a history of diverticular disease has left-sided pain and reports seeing blood in the stool. What is an important intervention for these symptoms? a. Ordering a CBC and stool for occult blood b. Prescribing an antispasmodic medication c. Referring the patient for a lower endoscopy d. Reminding the patient to eat a high- fiber diet ANS: C Patients with suspected diverticular abscess of rectal bleeding need further evaluation and a referral for lower endoscopy is warranted. Hemorrhage is more common from the right colon. The other actions do not have priority over the need to evaluate the cause of the bleeding. REF: Complications/Indications for Referral or HospitalizationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 134: Dysphagia Test Bank Multiple Choice 1. Which diagnostic study is best to evaluate a swallowing disorder? a. CT of the head and neck b. Electroglottography c. Electromyoscopy d. Videofluoroscopy ANS: D Videofluoroscopy is the most appropriate because it visualizes the actual swallow. Electroglottography and electromyoscopy may be appropriate, but are more limited. CT evaluation may aid in diagnosis, but does not describe the actual swallow mechanism. REF: Diagnostics 2. A patient has a feeding disorder after a stroke that causes disordered tongue function and impaired laryngeal closure. What intervention will be helpful to reduce complications in this patient? a. Surface electrical stimulation b. Teaching head rotation c. Thickened liquids d. Thinning liquids ANS: C Thickening liquids is helpful for patients with disordered tongue function and impaired laryngeal closure, because there is a reduced tendency for liquids to spill over the tongue base and cause aspiration. Surface electrical stimulation helps improve strength of muscles, but does not address the problem of aspiration. Teaching head rotation is used for patients with unilateral laryngeal dysfunction. Thinning liquids is used for patients with weak pharyngeal contraction. REF: Table 134-1: Swallowing Therapy Techniques, Rationales, and Indications 3. An elderly patient has recent weight loss and the patient’s spouse reports noticing coughing and choking when eating. What is the likely cause of this presentation? a. Esophageal dysphagiaTest Bank 2 b. Oralstage dysphagia c. Pharyngeal dysphagia d. Xerostomia causing dysphagia ANS: C Pharyngeal dysphagia often results from weakness or poor coordination of the pharyngeal muscles which can cause delayed swallow and failure of airway protection, leading to coughing and choking. Esophageal dysphagia is associated with pain after swallowing. Oral stage disorders are related to poor bolus control and result in drooling or spilling. Xerostomia is when oral mucous membranes are dry. REF: Clinical PresentationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 135: Gastroesophageal Reflux Disease Test Bank Multiple Choice 1. Which medications may increase the prevalence of GERD? a. Aspirin b. Benzodiazepines c. Calcium antagonists d. Hormone replacements e. Oral contraceptives ANS: A, B, C Aspirin, benzodiazepines, and calcium antagonists all increase the likelihood of GERD, while hormone replacement therapy and OCPs are associated with a lower incidence. REF: Clinical Presentation 2. A patient has been taking a proton pump inhibitor (PPI) for several months to treat GERD with rebound symptoms when discontinuing the medication. To minimize long-term side effects of the PPI, what regimen may be ordered? a. Alternate-day dosing of the PPI b. Switching to a histamine-2 receptor antagonist (H2RA) c. Taking a PPI and H2RA at different times a day d. Twice daily dosing of the PPI ANS: C Taking a PPI and an H2RA at different times a day is an alternate to high-dose PPI therapy. Alternate-day dosing of PPIs is not an effective long-term regimen. PPIs are superior to H2RAs. Twice daily dosing of the PPI will not minimize side effects. REF: Management 3. A patient experiences a sharp pain with swallowing just under the sternum. This is more commonly associated with which condition? a. Hiatal hernia b. Infectious esophagitis c. Peptic stricture d. Schatzki ringTest Bank 2 ANS: B A sharp, substernal pain with swallowing is most commonly associated with infectious esophagitis. Esophageal strictures are highly correlated with hiatal hernia and patients with stricture will report a feeling of food becoming stuck. A Schatzki ring and peptic stricture are types of strictures. REF: Clinical PresentationButtaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 136: Gastrointestinal Hemorrhage Test Bank Multiple Choice 1. A patient has both occasional ―coffee ground‖ emesis and melena stools. What is the most probably source of bleeding in this patient? a. Hepatic b. Lower GI c. Rectal d. Upper GI ANS: D Coffee ground emesis is