NSG 6420: FNP I Adult/Gero Final Review Study Guide

NSG 6420: FNP I Adult/Gero Final Review Study Guide 1. General Concepts in Geriatrics Impact of physiological changes with aging: Kennedy Chapter 1. The major impact of all of these physiological changes can be highlighted with three primary points. First, there is a reduced physiological reserve of most body systems, particularly cardiac, respiratory, and renal. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there is impaired immunological function: infection risk is greater, and autoimmune diseases are more prevalent. Reduced renal function, particularly the glomerular filtration rate (GFR), affects the clearance of many drugs, and creatinine clearance provides an index of renal function for use in choosing doses of renally eliminated or nephrotoxic drugs (such as digoxin, H2 blockers, lithium, and water-soluble antibiotics). Normal age related changes: Changes in kidney function begin in the fourth decade of life and continue to decline with each subsequent decade. by age 70, an individual might reasonably have a 40% to 50% decrease in renal function, even in the absence of disease. With advancing age, the ability of the liver to metabolize drugs does not decline. Although liver size and blood flow do decline with age, routine liver function test results are typically normal when no disease exists. Decreased liver size and blood flow can result in decreased first-pass metabolism. Older adults often experience more sedation from central nervous system drugs than younger persons at the same concentration. Signs and symptoms of depression: Altered presentation is another common feature in older adults. The patient with depression may not present with a dysphoric mood but rather agitation and psychotic features. Questions The major impact of the physiological changes that occur with aging is: Reduced physiological reserve Reduced homeostatic mechanisms Impaired immunological response All of the above All of the following statements are true about laboratory values in older adults except Reference ranges are preferable Abnormal findings are often due to physiological aging Normal ranges may not be applicable for older adults Reference values are not necessarily acceptable values Mini Mental Status: Buttaro Chapter 13 Geriatric specialists have multiple assessment tools, such as the Folstein Mini-Mental State Examination, the Mini-Cog screen for dementia, the Short Portable Mental Status Questionnaire, the AD8 Dementia Screening Interview, and the Montreal Cognitive Assessment (MoCa), to differentiate short-term memory loss from dementia and to observe the progression of cognitive impairment. Questions 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. 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 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 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 Examination 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 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 Immunizations 2. HEENT Pharyngitis Buttaro Chapter 101 In noninfectious pharyngitis the patient reports a sore throat and dryness; if environmental allergens are the cause, symptoms often include rhinorrhea, watery eyes, and postnasal drip. Viral causes are more common (rhinorivus) In viral pharyngitis, findings include fever, cough, nasal symptoms, and mild erythema with little or no pharyngeal exudate. Treatment of viral pharyngitis includes rest, fluids, humidification, voice rest, and warm saline gargles to ease discomfort. 7 Acetaminophen or ibuprofen should be used for fever and general discomfort. Bacterial pharyngitis is more common in children younger than 15. Streptococcus pyogenes is the etiologic agent for acute pharyngitis. Group A β-hemolytic Streptococcus (GAS) is the most important to identify because it is responsible for acute rheumatic fever (ARF) and poststreptococcal glomerulonephritis. Patients may report a sudden onset of sore throat, painful swallowing, fever (temperature higher than 38.5° C [101.3° F]), chills, headache, nausea, vomiting, and abdominal pain. With bacterial pharyngitis, rhinitis, cough, conjunctivitis, and myalgias are not typically present. Diagnostic studies used to detect GAS infection include a throat culture, a rapid antigen detection test (RADT). Penicillin V, 500 mg 2-3 times daily for 10 days) is indicated in GAS pharyngitis primarily to prevent complications, such as suppurative tonsillitis, glomerulonephritis, and rheumatic fever. Clarithromycin, 250 mg twice daily for 10 days, is indicated for patients with penicillin allergy. questions 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 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. 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 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 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. c. The child should have radiographic studies to evaluate the need for tonsillectomy. d. Tonsillectomy is recommended based on this child’s history. 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 Mononucleosis (Buttaro Chapter 233) EBV-IM (Epstein-Bar Virus infectious mononucleosis) occurs most often in adolescents and young adults, with the highest incident at ages 15 to 19. Transmission of EBV-IM occurs through exposure to oropharyngeal secretions. The classic triad of symptoms of acute IM includes fever, pharyngitis, and lymphadenopathy. The typical adolescent with EBV-IM is seen with sore throat, fever, and lymph node and tonsillar enlargement. Additional common presenting symptoms include pharyngeal inflammation and transient palatal petechiae. Reports indicate that splenic enlargement occurs in 40% to 100% of cases and can be confirmed with ultrasound. An abdominal examination identifies splenomegaly and hepatomegaly. Rash and jaundice should be noted because they are associated with EBV-IM. he most useful laboratory test is the serologic test for heterophil antibodies. Treatment of uncomplicated EBV-IM is primarily supportive, including adequate hydration, nonsteroidal anti-inflammatory drugs or acetaminophen for fever reduction and myalgias. Individuals with splenomegaly should be encouraged to refrain from strenuous physical activity for 3 to 4 weeks to avoid the risk of splenic rupture Questions A patient with EBV-IM also has group A beta-hemolytic streptococcal pharyngitis and is being treated with amoxicillin. On the third day of treatment, the patient develops a rash. A urinalysis is normal. What does this indicate?