NURS HEALTH ASSESSMENT ,Buttaro: Primary Care, A Collaborative Practice, (All Chapters )5th Edition

Buttaro: Primary Care, A Collaborative Practice, 5th Ed. Chapter 1: The Evolving Landscape of Collaborative Practice Test Bank Multiple Choice 1. 1. Which assessments of care providers are performed as part of the Value Based Purchasing initiative? Select all that apply. a. a. Appraising costs per case of care for Medicare patients b. b. Assessing patients’ satisfaction with hospital care c. c. Evaluating available evidence to guide clinical care guidelines d. d. Monitoring mortality rates of all patients with pneumonia e. 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 1. 2. What was an important finding of the Advisory Board survey of 2014 about primary care preferences of patients? a. a. Associations with area hospitals b. b. Costs of ambulatory care c. c. Ease of access to care d. 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. a. Bonuses based on achievement of benchmarks b. b. Care coordination for chronic diseases c. c. Standards for minimum cash reserves d. 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 Organizations 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? f. a. Epidemiological studies g. b. Experimental design h. c. Qualitative studies i. 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? e. a. Adoption of interventions and clinical practices into routine clinical care f. b. Determination of the basis of disease and various treatment options g. c. Examination of safety and effectiveness of various interventions h. 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 1. 3. What is the purpose of Level II research? e. a. To define characteristics of interest of groups of patients f. b. To demonstrate the effectiveness of an intervention or treatment g. c. To describe relationships among characteristics or variables h. d. To evaluate the nature of relationships between two variables ANS: C 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 Research Chapter 4: The Patient, the Provider, and Primary Care: An Integrated Perspective Test Bank Multiple Choice 2. 1. A patient takes glucosamine chondroitin to help control osteoarthritis pain. Which medications, taken in conjunction with this medication, are of concern? j. a. Anticholinergic drugs k. b. Beta blocker medications l. c. Blood-thinning agents m. 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 Painless 2. 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? i. a. Because they are not FDA approved, they are not safe j. b. Dietary supplements are safer than most prescription medications k. c. Many supplements lack clear clinical evidence of efficacy l. 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 2. 3. Which dietary supplements have shown some effectiveness in reducing blood pressure in patients with hypertension? Select all that apply. i. a. Chromium picolinate j. b. Cinnamon k. c. CoQ10 l. d. Garlic extract m. 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 Hypertension Chapter 15: Obesity and Weight Management Test Bank Multiple Choice 3. 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? n. a. Electrocardiography o. b. Gallbladder ultrasonography p. c. Mammography q. 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 3. 2. Which medications are associated with weight gain? Select all that apply. m. a. Antibiotics n. b. Antidepressants o. c. Antihistamines p. d. Insulin analogs q. 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 Gain Chapter 16: Lifestyle Management Test Bank Multiple Choice 4. 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? r. a. Begin with a 45 to 60 minute workout s. b. Include a 1 to 2 minute warm up before exercise t. c. Maintain a heart rate between 80 and 128 beats per minute u. 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 4. 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? r. a. Evaluate the patient for impaired glucose tolerance s. b. Reassure the patient that these are normal values t. c. Suggest that the patient begin an exercise program u. 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. 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. n. a. Number of times per week eaten in restaurants o. b. Sodium and sugar intake p. c. Sources of daily dairy intake q. d. Total number of servings of fruits and vegetables r. 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 Cholesterol Chapter 116: Cardiac Diagnostic Testing: Noninvasive Assessment of Coronary Artery Disease Test Bank Multiple Choice 5. 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? v. a. Coronary artery calcium score w. b. C-reactive protein x. c. Exercise echocardiography y. 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 5. 2. Which risk assessment for coronary artery disease is recommended for all female patients? v. a. Coronary artery calcium score w. b. Electrocardiogram x. c. Exercise stress test y. 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 Women Chapter 117: Abdominal Aortic Aneurysm Test Bank Multiple Choice 6. 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? z. a. Immediate referral to a thoracic surgeon aa. b. Ordering computerized tomography angiography bb. c. Scheduling an MRI to evaluate for aortic disease cc. 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 6. 2. A 70-year-old male patient has an aortic aneurysm measuring 5.0 cm. The patient has poorly-controlled hypertension, and decompensated heart failure. What is the recommendation for treatment for this patient? z. a. Endovascular stent grafting of the aneurysm aa. b. Immediate open surgical repair of the aneurysm bb. c. No intervention is necessary for this patient cc. 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: Management Chapter 118: Cardiac Arrhythmias Test Bank Multiple Choice 7. 1. A patient reports sustained, irregular heart palpitations. What is the most likely cause of these symptoms? dd. a. Anemia ee. b. Atrial fibrillation ff. c. Extrasystole gg. 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 7. 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? dd. a. Evaluate the patient’s orthostatic vital signs ee. b. Monitor the patient’s heart rate while the patient is bearing down ff. c. Order an electrocardiogram and exercise stress test gg. 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 4. 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? s. a. Administration of intravenous adenosine t. b. Giving a beta blocker u. c. Providing a loading dose of digoxin v. 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 Tachycardia Chapter 119: Carotid Artery Disease Test Bank Multiple Choice 8. 1. According to current research, which are associated with a decreased incidence of stroke? hh. a. ≧7 servings of fruits and vegetables per day ii. b. B-complex vitamin supplements jj. c. Intensive insulin therapy in type 1 diabetes kk. d. Low-sugar soda ll. 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 8. 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? hh. a. Order a carotid duplex ultrasound ii. b. Order catheter-based angiography jj. c. Refer the patient to a neurosurgeon kk. 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 criterion-based 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: Diagnostics Chapter 120: Chest Pain and Coronary Artery Disease Test Bank Multiple Choice 9. 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? mm. a. Administer a second nitroglycerin tablet nn. b. Give the patient a beta blocker medication oo. c. Prescribe a calcium channel blocker mediation pp. 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 9. 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? ll. a. Administer heparin mm. b. Give the patient an oral beta blocker nn. c. Initiate fibrinolytic treatment oo. 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 PCI-capable 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 5. 3. Patients who meet the criteria for statin therapy to help prevent atherosclerotic cardiovascular disease are those with a history of w. a. a 10 year risk score of 5% and an LDL of 165 mg/dL. x. b. a 10 year risk score of 8% with an LDL of 80 mg/dL. y. c. a low-density lipoprotein (LDL) level 190 mg/dL. z. d. diabetes and an LDL between 40 and 70 mg/dL. aa. 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 Guidelines Chapter 121: Heart Failure Test Bank Multiple Choice 10. 1. A patient who has heart failure with reduced ejection fraction will have which symptoms? qq. a. Dyspnea and fatigue without volume overload rr. b. Impairment of ventricular filling and relaxation ss. c. Mild, exertionally related dyspnea tt. 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 10. 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? pp. a. Class I qq. b. Class II rr. c. Class III ss. 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 6. 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? bb. a. Assess serum potassium and sodium immediately cc. b. Discontinue the ACE inhibitor and prescribe an ARB dd. c. Provide reassurance that this is a benign side effect ee. 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 Inhibitors Chapter 122: Hypertension Test Bank Multiple Choice 11. 1. Which are causes of secondary hypertension? uu. a. Increased salt intake vv. b. Isometric exercises ww. c. Nonsteroidal anti-inflammatory drugs xx. d. Oral contraceptives yy. 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 11. 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? tt. a. Assess serum cortisol levels uu. b. Continue to monitor blood pressure at each health maintenance visit vv. c. Order urinalysis, CBC, BUN, and creatinine ww. 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 7. 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? ff. a. Add a beta blocker to the patient’s regimen gg. b. Admit to the hospital for evaluation and treatment hh. c. Increase the dose of the thiazide medication ii. 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: Management Chapter 123: Infective Endocarditis Test Bank Multiple Choice 12. 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? zz. a. Extra-cardiac abscess formation aaa. b. Haemophilus infection bbb. c. Mycotic aneurysm ccc. 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/Neurologic Findings 12. 2. A patient has native valve endocarditis. While blood cultures are pending, which antibiotics will be ordered as empiric treatment? xx. a. A beta-lactamase resistant penicillin and an antifungal drug yy. b. Imipenem-cilastin and ampicillin zz. c. Penicillin and an aminoglycoside antibiotic aaa. 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 8. 3. A patient who is on renal dialysis is diagnosed with infective endocarditis. What causative organisms are more likely in this patient? a. b. c. d. Enterococcal organisms Neisseria gonorrhea Pseudomonas aeruginosa 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 Endocarditis Chapter 124: Myocarditis Test Bank Multiple Choice 13. 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? ddd. a. Exercise is contraindicated for life eee. b. Exercise may resume when symptoms subside fff. c. He may resume exercise in 6 months ggg. 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 13. 2. Which test is diagnostic for diagnosing myocarditis? bbb. a. Echocardiogram ccc. b. Electrocardiogram ddd. c. Endomyocardial biopsy eee. 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 9. 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? jj. a. Autoimmune disorder kk. b. Bacterial infection ll. c. Protozoal infection mm. d. Viral infection ANS: D 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: Pathophysiology Chapter 125: Peripheral Arterial and Venous Insufficiency Test Bank Multiple Choice 14. 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? hhh. a. Digital subtraction angiography iii. b. Doppler ankle, arm index jjj. c. Magnetic resonance angiography kkk. 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 14. 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? fff. a. Buerger’s disease ggg. b. Cauda equina syndrome hhh. c. Diabetic neuropathy iii. 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 10. 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? nn. a. Daily aspirin therapy to prevent clotting oo. b. Statin therapy with clopidogrel pp. c. Walking slowly for 15 to 20 minutes twice daily qq. 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: Management Chapter 126: Valvular Heart Disease and Cardiac Murmurs Test Bank Multiple Choice 15. 1. Which are factors can cause a heart murmur? lll. a. Backward flow through a septal defect mmm. b. Backward flow into a normal vessel nnn. c. Forward flow into a dilated vessel ooo. d. High rates of flow through a normal valve ppp. 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 15. 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? jjj. a. Admit the patient to the hospital for evaluation and treatment kkk. b. Consult with the cardiologist to determine appropriate diagnostic tests lll. c. Continue to monitor the patient every 3 years mmm. 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 11. 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? rr. a. Aortic stenosis ss. b. Hypertrophic cardiomyopathy tt. c. Mitral valve prolapse uu. 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: Murmurs