NURS 6560 Final Exam / NURS6560N Final exam: Advanced Practice Care of Adults in Acute Care Settings II: (2020) (100 Q & A, Received Score 100%)

NURS 6560 Final Exam / NURS6560 Final Exam (Latest): Advanced Practice Care of Adults in Acute Care Settings II: Walden University Walden NURS 6560 Final Exam / Walden NURS6560 Final Exam (Latest): Walden University Question 1 P. E. is a 61-year-old female who presents for a postoperative visit following a gastric resection after a perforation of peptic ulcer. She reports feeling better, although it is taking longer than she expected. However, she says she is feeling better each day, her appetite is returning, and her incision is healing well. She is being discharged from surgical care and advised to continue her routine health promotion follow-up with her primary care provider. As part of her surgical discharge teaching, the AGACNP counsels P. E. that as a result of her gastric resection she will need lifelong follow-up of: A. Blood group substances B. Electrolytes C. Vitamin B12 D. Gastric pH Question 2 M. T. is a 71-year-old female who presents for evaluation of a ―lump on her chest.‖ She denies any symptoms—there is no pain, erythema, edema, ecchymosis, or open areas—it is just a lump. She has no idea how long it has been there and just noticed it a few weeks ago. Physical examination reveals a round, smooth, flesh-colored tumor. It is firm but not hard; it has smooth borders. It measures 6 cm in diameter and is non-tender to palpation. The AGACNP suspects that this is a classic presentation of the most common chest wall tumor known as a: A. Neurolemma B. Lipoma C. Hemangioma D. Lymphangioma Question 3 The AGACNP is receiving report from the recovery room on a patient who just had surgical resection for pheochromocytoma. He knows that which class of drugs should be available immediately to manage hypertensive crisis, a possible consequence of physical manipulation of the adrenal medulla? A. Alpha-adrenergic antagonists B. Beta-adrenergic antagonists C. Intravenous vasodilators D. Arteriolar dilators Question 4 A patient with suspected Cushing’s syndrome is being evaluated to establish the diagnosis and cause. Patients with an adrenal tumor typically will demonstrate: A. Low ACTH and low cortisol B. Low ACTH and high cortisol C. High ACTH and low cortisol D. High ACTH and high cortisol Question 5 Pneumatosis, or gas cysts, may form in the wall anywhere along the gastrointestinal tract; in some cases, they will produce symptoms such as abdominal discomfort, diarrhea with mucus, and excess flatulence. Treatment of pneumatosis most often involves: A. Several days of oxygen by face mask B. Hyperbaric oxygen C. Surgical resection D. Treatment of underlying disease Question 6 Jennifer is an RN applicant for a staff nurse position in the surgical ICU. She has had a screening PPD and comes back in 48 hours to have it read. There is a 12-mm induration at the site of injection. A chest radiograph is negative. The AGACNP knows that the next step in Jennifer’s evaluation and management should include: A. No further care, because the chest radiograph is negative B. Quantiferon serum assay for exposure C. Consideration of prophylactic therapy D. Beginning therapy for pulmonary TB pending sputum cultures Question 7 In myelodysplastic syndromes, the primary indications for splenectomy include: A. Major hemolysis unresponsive to medical management B. Severe symptoms of massive splenomegaly C. Sustained leukocyte elevation above 30,000 cells/µL D. Portal hypertension Question 8 The AGACNP is evaluating a patient who reportedly fell down a flight of steps. Her history is significant for several emergency room visits, but she denies any significant medical conditions. Some documentation in her chart indicates that she may have been subjected to physical abuse. Today she presents with a periorbital ecchymosis of the left eye and swelling in the left side of the face. Her neurologic examination is within normal limits. Which head imaging study would be most useful in assessing for findings consistent with a history of abuse? A. Radiographs B. CT scan without contrast C. MRI D. PET scan Question 9 The AGACNP is treating a patient with ascites. After a regimen of 200 mg of spironolactone daily, the patient demonstrates a weight loss of 0.75 kg/day. The best approach to this patient’s management is to: A. Continue the current regimen B. D/C the spironolactone and begin a loop diuretic C. Add a loop diuretic to the spironolactone D. Proceed to large-volume paracentesis Question 10 Which of the following is a true statement with respect to the use of corticosteroids in posttransplant patients? A. High-dose initial steroids are tapered to off over a period of 4 to 6 weeks posttransplant B. There is a strong interest in developing corticosteroid-free posttransplant protocols C. Better results are demonstrated in corticosteroid-free protocols for second-transplant recipients D. Evidence supports corticosteroid-free rejection protocols Question 11 K. T. presents for a routine wellness examination, and the review of systems is significant only for a markedly decreased capacity for intake and a vague sense of nausea after eating. K. T. denies any other symptoms; the remainder of the GI review of systems is negative. His medical history is significant for complicated peptic ulcer disease that finally required resection for a perforated ulcer. The AGACNP advises the patient that: A. He will need endoscopy to evaluate the problem B. Chronic gastroparesis is a known complication of ulcer surgery C. Medication is unlikely to help, and he may need another surgery D. His symptoms occur in 5 to 10% of people after ulcer surgery Question 12 The AGACNP is rounding on a patient following splenectomy for idiopathic thrombocytopenia purpura. On postoperative day 2, a review of the laboratory studies is expected to reveal: A. Increased MCV B. Increased Hgb C. Increased platelets D. Increased albumin Question 13 A patient being monitored post-heart transplant suffers a bradyarrhythmia. The AGACNP knows that which of the following medications is not indicated as part of emergency intervention for bradycardic abnormalities in a posttransplant patient? A. Isoproterenol 0.2 to 0.6 mg IV bolus B. External pacemaking C. Atropine 0.5 mg IV D. Epinephrine 1 mg IV Question 14 Ms. Carpenter is a 28-year-old female who presents in significant pain; she indicates that the discomfort is in the right lower quadrant. The discomfort is colicky in nature and has the patient in tears. Which of the following associated findings increases the index of suspicion for ureteral colic? A. Temperature 102°F B. White blood cell count 14,000 cells/µL C. Vomiting D. Hematuria Question 15 Which of the following is not a true statement with respect to decision making for a cognitively impaired patient? A. Only a court can declare a patient incompetent B. Impaired cognition does not make a person incompetent C. Living wills typically are honored if a person is terminally ill D. A patient can give informed consent if not declared incompetent Question 16 Hepatic encephalopathy is a clinical syndrome seen in patients with chronic liver disease; its presentation may range from mild personality changes, to psychosis, to coma. The primary chemical mediators of hepatic encephalopathy include all of the following except: A. Gamma-aminobutyric acid (GABA) B. Ammonia C. False neurotransmitters D. Serotonin Question 17 Ross A. is a 38-year-old who has just had a kidney transplant. The AGACNP knows that, due to the characteristic and anticipated response of transplanted kidneys, the patient requires: A. Aggressive rehydration B. Controlled hydration C. Hypertonic rehydration D. Isotonic rehydration Question 18 Janice is a 32-year-old female who presents for evaluation of abdominal pain. She has no significant medical or surgical history and denies any history of ulcers, reflux, or gastritis. However, she is now in significant pain and is afraid something is ―really wrong.‖ She describes what started out as a dull discomfort in the upper part of her stomach a few hours ago but has now become more profound and centered on the right side just under her ribcage. She has not vomited but says she feels nauseous. Physical exam reveals normal vital signs except for a pulse of 117 bpm. She is clearly uncomfortable, and palpation of the abdomen reveals tenderness with deep palpation of the right upper quadrant. The AGACNP orders which imaging study to investigate the likely cause? A. Abdominal radiographs B. CT scan of the abdomen with contrast C. Right upper quadrant ultrasound D. A HIDA scan Question 19 Justin F. is seen in the emergency department with an 8-cm jagged laceration on the dorsal surface of his right forearm. He says he was working with his brother-in-law yesterday morning building a deck on the back of his home. A pile of wooden planks fell on top of him, and he sustained a variety of cuts and superficial injuries. He cleaned the wound with soap and water but didn’t want to go to the emergency room because he didn’t want to risk being in the waiting room for hours. He wrapped up his arm and went back to work, and then took a normal shower and went to bed last night. This morning the cut on his arm was still flapping open, and he realized he needed sutures. The appropriate management of this patient includes: A. Proper cleansing and covering of the laceration, along with antibiotic therapy B. Local anesthesia, cleansing, and wound exploration for foreign bodies C. Local anesthesia, cleansing, and suture repair D. Cleansing, covering, antibiotic therapy, and tetanus prophylaxis Question 20 T. O. is a 44-year-old female patient who presents for evaluation of sudden, severe upper abdominal pain. She is clear about the onset, which was profound and occurred approximately one hour ago. She denies that the onset had any relationship to food or eating, and she denies nausea or vomiting. On examination, she is lying on her right side with her hips and knees flexed to draw her knees to her chest. Vital signs are stable, but examination reveals involuntary guarding. The abdomen is painful and tympanic to percussion in all quadrants. CBC reveals a white blood cell count of 15,600/µL. The AGACNP suspects: A. Dissecting aortic aneurysm B. Acute pancreatitis C. Perforated peptic ulcer D. Mallory-Weiss tear Question 21 A 42-year-old woman presents to the emergency department after being raped. The AGACNP examines her and realizes that the patient’s husband is the rapist. The patient does not want to press charges and wants to return home with her husband. The AGACNP’s initial action should be to: A. Report the physical assault to law enforcement B. Have the patient sign a release to go home with her husband C. Consult psychiatry for a psych hold D. Provide counseling to the patient regarding her options Question 22 M. R. is a 52-year-old female who presents complaining of significant abdominal pain, which she rates as 8 to 9 on a 1 to 10 scale. The pain has been going on for a matter of hours, and she is afraid it won’t go away on its own. She denies any nausea or vomiting, and she cannot remember precisely when her last bowel movement occurred; probably it was a few days ago. She reports that she is ―always‖ constipated. On physical examination, she is tachycardic but otherwise has normal vital signs; her abdomen is tensely rigid, but no point tenderness to palpation is appreciated. The entire abdomen percusses as tympanic—there is no distinct dullness over the upper quadrants. Bowel sounds are present but hypoactive and intermittent. There is rebound tenderness to palpation. The AGACNP suspects: A. Perforated bowel B. Peritonitis C. Ischemic bowel D. Intestinal abscess Question 23 C. V. is a 70-year-old African American male patient who presents for surgical consultation. His history includes 4 months of severe hypertension that has been poorly responsive to medication. He also complains of intermittent pounding headaches, palpitations, and a vague sense of anxiety with tremors. A 24-hour urine demonstrated elevated metanephrines. The AGACNP recognizes that this patient has a: A. Malignant hyperthyroidism B. Catecholamine-secreting tumor C. Pituitary adenoma D. Hyperaldosteronism Question 24 The AGACNP knows that when evaluating a patient with suspected acute pyelonephritis, which of the following is not a common feature? A. Pyuria B. Fever C. CVA tenderness D. Gross hematuria Question 25 B. T. is a 49-year-old male who has been admitted for the management of an episode of diverticulitis. This is his fifth hospitalization this year, and in previous hospitalizations he has had both abscess and stricture as a consequence of his disease. His treatment this hospitalization should include: A. Extended-spectrum antibiotics B. Surgical consultation for colectomy C. Expectant treatment with nonabsorbable antibiotics D. Colonoscopy Question 26 Based upon an understanding of the normal relationship between gastrin levels and acid secretion, the AGACNP recognizes that which of the following combinations is almost diagnostic of gastrinoma? A. Hypogastrinemia and acid hyposecretion B. Hypergastrinemia and acid hyposecretion C. Hypogastrinemia and acid hypersecretion D. Hypergastrinemia and acid hypersecretion Question 27 The AGACNP is covering an internal medicine service and is paged by staff to see a patient who has just pulled out his ET tube. After the situation has been assessed, it is clear that the patient will go into respiratory failure and likely die if he is not reintubated. The patient is awake and alert and is adamant that he does not want to be reintubated. The AGACNP is concerned that there is not enough time to establish a DNR—the patient needs to be reintubated immediately and already is becoming obtunded. Which ethical principles are in conflict here? A. Veracity and beneficence B. Beneficence and nonmalfeasance C. Autonomy and beneficence D. Justice and autonomy Question 28 R. S. is a 66-year-old female with Cushing’s syndrome due to an ACTH-producing pituitary tumor. The tumor is readily isolated by imaging, and the patient had an uneventful surgery. When seeing her in follow-up, the AGACNP anticipates: A. Rapid reversal of symptoms, with good pituitary function B. Transient rebound release of remaining pituitary hormones C. Markedly improved dexamethasone suppression test D. Hyponatremia and compensatory SIADH Question 29 A 16-year-old male presents with fever and right lower quadrant discomfort. He complains of nausea and has had one episode of vomiting, but he denies any diarrhea. His vital signs are as follows: temperature 101.9°F, pulse 100 bpm, respirations 16 breaths per minute, and blood pressure 110/70 mm Hg. A complete blood count reveals a WBC count of 19,100 cells/µL. The AGACNP expects that physical examination will reveal: A. Murphy’s sign B. Chvostek’s sign C. McBurney’s sign D. Kernig’s sign Question 30 N. C. is a 60-year-old female with primary hyperaldosteronism. She has been referred to your service for surgical management. Anticipated findings on clinical history would include: A. Palpitations, headaches, and sweating B. Polyuria, weakness, and paresthesias C. Dry skin, straie, and unplanned weight loss D. Early satiety, tremors, and fatigue Question 31 Mrs. Maroldo is an 81-year-old female who presents for evaluation of pain in her left lower quadrant. She has had this pain before and says she usually takes antibiotics and it goes away. However, this time it seems worse, and she has had it for 4 days even though she says she started taking her leftover antibiotics from the last episode. She denies any nausea or vomiting but says she simply isn’t hungry. She had a little diarrhea yesterday but no bowel movements today. She has a temperature of 100.9°F and a pulse of 104 bpm, respirations of 20 breaths per minute, and a blood pressure of 94/60 mm Hg. She has some discomfort to deep palpation in the left lower quadrant. The AGACNP suspects: A. Irritable bowel syndrome B. Inflammatory bowel disease C. Diverticulitis D. Appendicitis Question 32 In the majority of cases, the first clinical manifestation of physiologic stress ulcer is: A. Epigastric pain B. Change in mental status C. Fever D. Hemorrhage Question 33 A patient with chronic hepatic encephalopathy is being discharged home. Discharge teaching centers upon long-term management strategies to prevent ammonia accumulation. Teaching for this patient includes instruction about: A. Lactulose taken 20 g PO daily B. Spironolactone taken 100 mg PO daily C. Protein intake of 50 g daily D. Zolpidem taken 10 mg PO qhs. Question 34 R. R. is a 61-year-old male patient who presents with a chief complaint of fever and urinary symptoms. He was in his usual state of good health when for no apparent reason he developed pain in his back and perineal region, as well as fever and chills. He presents as septic. He had urinary hesitancy and decreased stream but now reports that he has not passed urine in more than 12 hours. Palpation of the lower abdomen is consistent with bladder distention. The AGACNP knows that which of the following is contraindicated in this circumstance? A. Digital prostate examination B. Urinary catheterization C. Fluoroquinolone antibiotics D. Drainage of prostate abscess Question 35 On postoperative day 7 following hepatic transplant, the patient evidences signs and symptoms of acute rejection, confirmed by histologic examination. The AGACNP knows that first-line treatment of acute rejection consists of: A. Cyclosporine B. Azathioprine C. Methylprednisolone D. Sirolimus Question 36 R. R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. Which diagnostic test is most likely to support the leading differential diagnosis? A. CT scan with IV, oral, and rectal contrast B. CBC with WBC differential C. Colonoscopy D. Barium enema Question 37 Ms. O’Reilly is a 69-year-old patient who is having a bowel resection for a malignant tumor of the right colon. She has several chronic medical conditions and takes numerous daily medications, including metoprolol 100 mg daily, warfarin 5 mg daily, vitamin E 200 units daily, and metformin 1000 mg bid. Which of the following regimens is the most appropriate approach to managing her medications preoperatively? A. All medications should be taken up to and including the morning of surgery B. The beta blocker may be taken up until the day of surgery, metformin should be held the day of surgery, and the remaining medications should be d/c’d 5–7 days before surgery C. Warfarin should be held 5 days before surgery; all other medications may be taken through the morning of surgery D. Metformin should be held if the morning blood sugar is 200 mg/dL; all other medications except warfarin may be given the day of surgery Question 38 Mr. Novello is an 81-year old male patient who presents with crampy abdominal pain in the hypogastrum and a vague history as to his last normal bowel movement. Physical examination reveals distention and high-pitched bowel sounds. The patient says he has never has this kind of problem before and denies any history of abdominal surgery. Abdominal radiographs reveal a frame pattern of colonic distention. The AGACNP considers: A. A stimulant laxative to relieve bowel contents B. Carcinoma of the bowel as a leading diagnosis C. Decompression of the colon with rectal tube D. Angiography to rule out mesenteric ischemia Question 39 Jane S. is a 35-year-old female patient who is at 30 weeks gestation. She is being followed regularly for prenatal care and has always been healthy; she just had an office visit and was told everything was fine. Tonight she presents to the emergency room complaining of significant pain in the upper abdomen. Her vital signs reveal a temperature of 98.4°F, pulse of 110 bpm, respirations of 20 breaths per minute, and blood pressure of 144/90 mm Hg. A urinalysis reveals proteinuria, and a metabolic panel is significant for increased transaminases. Her hemogram is normal, but the CVC reveals platelets of 85,000. The AGACNP knows that which of the following must be evaluated as a cause of her abdominal pain? A. HELLP syndrome B. Placental abruption C. Spontaneous hepatic rupture D. Preterm labor Question 40 Which of the following statements is true with respect to adrenal tumors that produce gender symptoms? A. Feminizing adrenal tumors are almost always carcinomas B. Feminizing adrenal tumors are the most common type of adrenal tumor C. Virilizing tumors in women are most often localized to the adrenal cortex D. Virilizing adrenal tumors are more likely to be malignant in children Question 41 G. D. is a 13-year-old male patient who has a history of recurrent fever and flank pain. His parents traditionally are not believers in the health care system, and he has not been seen by a health care provider for many years. Today he has fever, chills, and costovertebral angle tenderness. Urinalysis reveals findings consistent with acute urinary infection. The AGACNP treats the patient for pyelonephritis and considers which study to evaluate for vesicoureteral reflux? A. Bilateral renal ultrasound B. CT scan of the abdomen and pelvis C. Voiding cystourethrograpy D. Radioisotope scanning Question 42 In which form of hypospadias should circumcision be deferred in order to preserve the prepuce for later surgical repair? A. Ventral displacement B. Proximal displacement C. Midscrotal hypospadias D. Meatus proximal to the corona Question 43 T. G. is a 48-year-old female who presents with biliary colic. She has had previous episodes but has resisted operation because she is afraid of anesthesia. Today her physical exam reveals a clearly distressed middle-aged female with right upper quadrant pain, nausea, and vomiting. Which of the following findings suggests a complication that requires a surgical evaluation? A. A temperature of 101.5°F B. A leukocyte count of 18,000/µL C. A palpable gallbladder D. A positive Murphy’s sign Question 44 Achalasia is a risk factor for: A. Squamous cell carcinoma B. Gastroesophageal reflux disease C. Esophageal atrophy D. Malabsorption syndromes Question 45 Carolyn C. has a history of Crohn’s disease and has been managed with immunologic agents, with moderate success. Today she presents with severe abdominal pain that comes and goes in waves; it started shortly after she ate a little bit of cottage cheese and crackers. This has never happened before with her Crohn’s disease. She has difficulty localizing the pain but seems to indicate the general area of the umbilicus. She had one episode of diarrhea this morning. Abdominal examination is nonspecific, producing mild tenderness on palpation. Plain abdominal films reveal a dilated small bowel with air fluid levels. The AGACNP suspects: A. Perforated small bowel B. Ulceration through the thickness of small bowel C. Small bowel obstruction D. Gastroenteritis Question 46 S. B. is a 41-year-old female who presents complaining of constipation. She says she has never had problems with bowel movements in the past, although she has heard that constipation is common among women. She says that for the last month or so she has been lucky to have three bowel movements a week, and even when she has one, she doesn’t always feel empty. A review of systems is otherwise negative, and she denies taking any new medications. She denies depression or any mood disorders—she says she actually is very happy and has always felt well, but this bowel problem is bothering her. She has tried over-the-counter products such as Metamucil® and stool softeners, but nothing has helped. Her abdominal, pelvic, and rectal examinations are normal—there are good bowel sounds, no organomegaly, and no discomfort on palpation. The AGACNP considers ordering: A. Stool for occult blood B. Colonic transit assessment C. Contrast CT of the abdomen D. Plain film radiography Question 47 Neoadjuvant chemotherapy treatment for cancer is given to facilitate surgical resection. When the outcomes of cancer therapies are evaluated, the terms complete response and partial response often are used. Partial response means that: A. 50% of the patients treated with a given regimen demonstrate remission B. 50% of the patients treated survive to the 5-year point C. The tumor mass has reduced by 50% D. In 50% of cases, the tumor converts from unresectable to resectable Question 48 In the preoperative assessment of a patient for the likelihood of postoperative risk, ascorbic acid deficiency, anemia, and volume contraction are all risk factors for: A. Prolonged intubation B. Thromboembolism C. Delayed wound healing D. Atelectasis Question 49 Mr. Thornton is a 55-year-old man who is having an outpatient cardiac workup for the evaluation of exertional chest pain. He is not having chest pain now, but over the last several months he has had episodes of intermittent chest tightness and shortness of breath with mild to moderate exertion, such as when carrying heavy bags of groceries from the car to the house. His 12-lead ECG today reveals Q waves that range from 2 to 3 mm wide and 3–4 mm deep in leads V1 through V5. There are no other abnormal findings. This suggests that Mr. Thornton: A. Is having anterior wall ischemia B. Is having an anterior wall infarction C. Has a history of anterior wall NSTEMI D. Has a history of anterior wall STEMI Question 50 Which of the following types of aortic aneurysms requires immediate surgical intervention? A. Type A B. Type B C. Descending D. Symptomatic Question 51 When examining a patient with abdominal pain, the AGACNP knows that tenderness to percussion is analogous to: A. Tympany B. Guarding C. Rebound tenderness D. Somatic pain Question 52 Janet is a 54-year-old female who is in the ICU following hepatic resection due to metastatic disease. She is expected to move to a general medical floor today. Morning labs are as follows: serum bilirubin approximately 2 g/dL, albumin 3.1 g/dL, and prothrombin time 20 seconds. AST and ALT are 85 and 99 respectively. The appropriate response would be to: A. Cancel the transfer and keep her in the ICU B. Infuse albumin and fresh frozen plasma C. Repeat the labs the next day D. Prepare for reoperation Question 53 Lester R. is a 58-year-old male who is being evaluated for nocturia. He reports that he has to get up 2 to 3 times nightly to void. Additional assessment reveals urinary urgency and appreciable post-void dribbling. A digital rectal examination reveals a normal-sized prostate with no appreciable hypertrophy. The best approach to this patient includes: A. Administration of the American Urological Association (AUA) Symptom Scale B. Laboratory assessment to include a PSA C. Ordering a prostate ultrasound D. Assessment of nonprostate causes of nocturia Question 54 K. W. is a 50-year-old woman who presents for surgical resection of the liver for treatment of metastatic colon cancer. Preoperatively, the surgeon tells her that he is planning to remove 50 to 75% of her liver. The patient is concerned that she will not be able to recover normal liver function with that much removed. The AGACNP counsels her that: A. Such a high-volume resection is utilized only in people with markedly compromised hepatic function B. Major regeneration occurs within 10 days, and the process is complete by 5 weeks C. Liver function will probably recover to 50% baseline, but that is enough for normal function D. Up to 95% of the liver can be removed without any apparent consequence to the patient Question 55 A student AGACNP just beginning his clinical rotation is observing his preceptor perform a physical survey on a patient who is brought in following a serious motor vehicle accident. The student observes that the physical examination includes rectovaginal examination, inspection of the urethral meatus, and palpation of the pelvic landmarks. The student knows the patient is being assessed for: A. Peritoneal bleeding B. Retroperitoneal bleeding C. Paresthesia D. Pelvic fracture Question 56 S. R. is a 51-year-old male patient who is being evaluated for fatigue. Over the last few months he has noticed a marked decrease in activity tolerance. Physical examination reveals a variety of ecchymoses of unknown origin. The CBC is significant for a Hgb of 10.1 g/dL, an MCV of 72 fL and a platelet count of 65,000/µL; the remainder of the CBC is normal. Coagulation studies are normal, but bleeding time is prolonged. The AGACNP recognizes that initial management of this patient will include: A. Avoidance of elective surgery and nonessential medications B. Prednisone 60 mg daily until platelets normal C. Monoclonal antibody therapy such as rituximab D. Splenectomy Question 57 The AGACNP is counseling a patient about various methods of tumor biopsy. Which of the following is not an accurate statement? A. Incisional biopsy is preferred to excisional biopsy when possible B. Core needle biopsy has a higher rate of false positive than does fine needle aspiration C. Fine needle aspiration does not allow grading of tumors D. Core needle and incisional biopsies are virtually identical in terms of false results Question 58 The AGACNP recognizes that which of the following diagnostic studies is essential in all cases of acute abdomen? A. Abdominal radiograph B. Contrast radiography C. Chest radiography D. Ultrasonography Question 59 Flexion-distraction injuries of the thoracolumbar spine are most commonly caused by: A. Blunt trauma B. Rotational injury C. Seat belts D. Gunshot wounds Question 60 T. S. is a 31-year-old female who is admitted following a catastrophic industrial accident. She had multiple injuries, and after a 10-day hospital stay that included several operations and attempts to save her, she is declared brain dead. She had an organ donor notation on her driver’s license. Which of the following circumstances precludes her from serving as a liver donor? A. Encephalopathy B. Hepatitis C infection C. A long history of alcohol use D. Biliary cirrhosis Question 61 When counseling a patient about his surgical options for an ulcer that has been refractory to medical therapy, the AGACNP advises the patient that he will need: A. Lifelong vitamin D replacement B. Excision of the ulcer, which produces an 80% cure rate C. To eat much smaller, more frequent meals D. Some form of vagotomy Question 62 Jake is a 32-year-old patient who is recovering from major abdominal surgery and organ resection following a catastrophic motor vehicle accident. Due to the nature of his injuries, a large portion of his jejunum had to be resected. In planning for his recovery and nutritional needs, the AGACNP considers that: A. He will probably be able to transition to oral nutrition but will have lifetime issues with diarrhea B. His procedure has put him at significant risk for B12 absorption problems C. Most jejunum absorption functions will be assumed by the ileum D. Enteral nutrition will need to be delayed for 3 to 6 months to facilitate adaptation Question 63 Mr. Costigan is a 50-year-old male patient who recently had a screening colonoscopy because it was recommended by his primary care provider as a screening measure. He received a report that noted inflammatory polyps. He is concerned because one of his friends had polyps that ―turned into‖ cancer. While advising Mr. Costigan, the AGACNP tells him that: A. The polyps are considered precancerous, but if he has a colonoscopy every 3 to 5 years, any new polyps can be removed before they become malignant B. The primary danger is when there is a family history of colon cancer; he should discuss with his mother and father the presence of any colon cancer in the family C. There is no chance that these polyps could become cancerous, and their presence does not require any additional action or concern on his part D. He would be best served at this point to discuss with an oncologist the risks and benefits of aggressive versus conservative treatment. Question 64 enna is a 41-year-old female who presents to the emergency room complaining of sudden hearing loss. She is generally very healthy—she denies any significant medical history, and her only daily medication is a combined oral contraceptive. She does admit that she is just getting over a ―head cold,‖ but other than that she offers no relevant history. A comprehensive history and physical examination results in a diagnosis of sudden sensorineural hearing loss (SSHL) of unknown origin. The AGACNP knows that the next step in the patient’s management should include: A. Acyclovir B. Furosemide C. Warfarin D. Hyperbaric oxygen Question 65 A patient presents with a 2-day history of abdominal pain, fever, vomiting, and diarrhea. A surgical abdomen is ruled out, and radiography demonstrates inflammation of the small bowel and colon. Microscopy supports a diagnosis of Campylobacter jejuni, and the patient is prepared for discharge from the emergency room. Important patient education includes advising her that: A. The bacteria may be spread for as long as she has diarrhea B. The disorder should resolve on its own; recurrence is rare but represents a much more serious condition C. She will need to take a 10-day course of antibiotics D. There is no readily identified food source of this bacteria Question 66 While reviewing the head CT scan of a patient following a motor vehicle accident, the AGACNP appreciates a crescent-shaped fluid collection. This most likely represents: A. Acute subdural hematoma B. Acute epidural hematoma C. Acute uncal herniation D. Acute brainstem compression Question 67 Sara S. is a 41-year-old patient who has just had a bone marrow transplant. The AGACNP knows that which medication will be used to decrease her risk of graft-versus-host reaction? A. Immune globulin B. Cyclosporine C. Prophylactic antibiotics D. Systemic corticosteroids Question 68 H. W. is a 33-year-old female who is being evaluated after a fall from a tree. Anteroposterior and lateral radiographs of the thoracolumbosacral spine are significant for transverse process fractures at T6 and T7. The AGACNP knows that treatment for this likely will include: A. Observation B. Hyperextension casting C. Jewett brace D. Surgical intervention Question 69 When evaluating a patient with acute pancreatitis, which of the following physical or diagnostic findings is an ominous finding that indicates a seriously ill/potentially moribund patient? A. Severe epigastric pain with radiation to the back B. Abdominal guarding and rigidity C. Grey Turner sign D. Obturator sign Question 70 P. T. is a 58-year-old female who is admitted with chest pain and shortness of breath and is found to have a large pulmonary embolus. Her systolic blood pressure is falling, and a diagnosis of obstructive shock is made. Cardiac pressure would likely demonstrate: A. Elevated atrial and decreased ventricular pressures B. Elevated right-sided and decreased left-sided pressures C. Elevated left ventricular pressure and decreased cardiac output D. Elevated left ventricular pressure and decreased systemic vascular resistance Question 71 Mrs. Jenner is a 41-year-old female who is being evaluated for persistent nausea. She had an abdominal CT scan that reported three hepatic hemangiomas ranging from 3 to 5 cm. The AGACNP knows that the appropriate response to this report is to: A. Arrange for large-bore needle biopsy B. Order hepatic ultrasound annually to follow progression C. Consult surgery for resection D. Document the finding in the patient’s chart Question 72 A patient admitted for management of sepsis is critically ill and wants to talk with a hospital representative about donating her organs if she dies. She has a fairly complex medical history that includes traumatic brain injury, breast cancer, and dialysis-dependent renal failure. The patient is advised that she is ineligible to donate due to her: A. Renal failure B. Traumatic brain injury C. Gram negative infection D. Breast cancer Question 73 Mr. Jefferson is a 59-year-old male who presents to the emergency department complaining of severe abdominal pain. His medical history is significant for dyslipidemia, and he takes 40 mgof simvastatin daily. He admits to drinking 6 to 10 bottles of beer nightly and to smoking 1½ packs of cigarettes a day. He denies any history of chest pain or cardiovascular disease. He was in his usual state of good health until a couple of hours ago, when he developed this acute onset of severe pain in the upper abdomen. He says that he tried to wait it out at home but it was so bad he finally came in. His vital signs are as follows: temperature 99.1°F, pulse 129 bpm, respirations 22 breaths per minute, and blood pressure 137/84 mm Hg. The abdomen is diffusely tender to palpation with some guarding but no rebound tenderness. The AGACNP anticipates that which of the following laboratory tests will be abnormal? A. A complete blood count and RBC differential B. Liver function enzymes C. Serum amylase, lipase, and glucose D. A basic metabolic panel Question 74 Melanie is a 31-year-old patient who is being evaluated following a routine urinalysis that revealed microscopic hematuria. She was between menses and has no other identifiable explanation for hematuria. She has no significant medical history and otherwise is without complaint. The AGACNP knows that workup for Melanie should include: A. A urology consultation B. CT urogram C. Upper urinary imaging D. Cystoscopy Question 75 The comprehensive serologic assessment of a patient with Cushing’s syndrome is likely to produce which constellation of findings? A. Low potassium, high glucose, high white blood cell count B. High sodium, polycythemia, low BUN C. Low sodium, low potassium, high BUN D. High sodium, high chloride, high RBCs Question 76 While participating in sports, it is not uncommon for people to be subjected to sudden rotational injuries that result in the abrupt rotation of the cerebral cortex around the more fixed midbrain structures. This can interrupt input and outflow from the reticular activating system and result in what clinical phenomenon? A. Epidural hematoma B. Uncal herniation C. Concussion D. Contrecoup injury Question 77 L. D. is a 24-year-old male who is transported to the emergency department after being assaulted in a neighborhood bar. The history is unclear, but witnesses agree that L. D. was assaulted and repeatedly had his head banged against the hard granite surface of the bar. On presentation he has marked edema of his face, multiple ecchymoses including both periorbital regions, and a Glasgow Coma Scale (GCS) score of 9. He has had 1 L of NSS infused by emergency medical services. His vital signs reveal a pulse of 128 bpm and a blood pressure of 88/60 mm Hg. With respect to his hypotension, the AGACNP recognizes that: A. Vasopressors are contraindicated in traumatic head injury B. Hypotension doubles the risk of mortality from traumatic head injury C. His blood pressure is likely a physiologic response to traumatic head injury D. Stabilizing the head injury is more important that identifying the cause of hypotension Question 78 With respect to tumor nomenclature, the AGACNP knows that the term carcinoma describes: A. Malignant neoplasms of internal structure B. Tumors that have lost normal growth regulation C. A dysfunctional metaplastic adaptation D. Neoplasms of epithelial origin Question 79 The Brain Trauma Foundation recommends intracranial pressure monitoring for all of the following patients except those with : A. GCS of 3 to 8 and abnormal head CT B. GCS of 3 to 8 and hypotension C. GCS of 3 to 8 and 40 years old D. GCS of 3 to 8 and bradycardia Question 80 A general principle in surgical oncology is that the best approach to curative surgery in a fixed tumor requires: A. En bloc resection B. Adjuvant therapies C. Neoadjuvant therapies D. Elective lymph node dissection Question 81 The relationship between abdominal pain and vomiting typically can be characterized by saying: A. When the vomiting precedes pain, the likelihood of surgical abdomen increases appreciably B. Conditions that may produce only mild nausea in the younger patient often will cause vomiting in older patients C. The majority of surgical abdomens do not produce vomiting as a primary symptom D. The presence of bile in vomitus suggests pyloric stenosis Question 82 Jasmine is a 31-year-old female who presents with neck pain. She has a long history of injection drug use and admits to injecting opiates into her neck. Physical examination reveals diffuse tracking and scarring. Today Jasmine has a distinct inability to turn her neck without pain, throat pain, and a temperature of 102.1°F. She appears ill and has foul breath. In order to evaluate for a deep neck space infection, the AGACNP orders: A. Anteroposterior neck radiography B. CT scan of the neck C. White blood cell (WBC) differential D. Aspiration and culture of fluid Question 83 Mr. Mettenberger is being discharged following his hospitalization for reexpansion of his second spontaneous pneumothorax this year. He has stopped smoking and does not appear to have any overt risk factors. While doing his discharge teaching, the AGACNP advises Mr. Mettenberger that his current risk for another pneumothorax is: A. 10% B. 25-50% C. 50-75% D. 90 Question 84 Traumatic diaphragmatic hernias present in both acute and chronic forms. Patients with a more chronic form are most likely to be present with: A. Respiratory insufficiency B. Sepsis C. Bowel obstruction D. Anemia Question 85 The AGACNP is managing a patient in the ICU who is being treated for a pulmonary embolus. Initially the patient was stable, awake, alert, and oriented, but during the last several hours the patient has become increasingly lethargic. At change of shift, the oncoming staff nurse appreciates a profound change in the patient’s mental status from the day before. Vital signs and hemodynamic parameters are as follows: BP 88/54 mm Hg Pulse 110 bpm Respiratory rate 22 breaths per minute SaO2 93% on a 50% mask Systemic vascular resistance (SVR) 1600 dynes ∙ sec/cm5 Cardiac index 1.3 L/min Pulmonary capillary wedge pressure (PCWP) 8 mm Hg This clinical picture is most consistent with which shock state? A. Hypovolemic B. Cardiogenic C. Distributive D. Obstructive Question 86 The AGACNP is going over preoperative information and instructions with a patient who is having a major transverse abdominal procedure tomorrow morning. The patient is very nervous and is asking a lot of questions. The AGACNP prescribes a sleeping agent because he knows that anxiety and sleeplessness may: A.Lead to hypoxia due to hyperventilation B. Increase the physiologic stress response postoperatively C. Contribute to risk of delirium and prolonged length of stay D.Decreasep.o. intake and produce nutritional risk Question 87 When counseling a patient about treatment modalities for achalasia, the AGACNP advised that which of the following is the treatment of choice? A.Calcium channel antagonists B. Intrasphincter botulinum injection C. Pneumatic dilation D.Myotomy and partial fundoplication Question 88 V. is a 75-year-old male patient who, during a recent wellness evaluation, was found to have a new onset grade II/VI crescendo-decrescendo cardiac murmur at the 2nd intercostal space, right sternal border. He is symptom free and reports no limitations to his usual daily activity. He specifically denies activity intolerance or near syncope, and he is very active physically. Echocardiography reveals a mild aortic calcification. The AGACNP knows that ongoing management for R. V. must include: A.Annual or biannual serial echocardiography B. Modification of activity level C. Baseline cardiac catheterization D. Statin therapy Question 89 W. is a 49-year-old man who presents for evaluation. He has a long history of alcohol and tobacco use, with a 65-year pack history and an admitted 14-drink-per-week alcohol habit. He is getting worried because he can no longer swallow his bourbon. He is not a good historian but he does admit to a 1 year history of bloating, heartburn, and progressive difficulty swallowing food. He didn’t worry too much about his symptoms until he stopped being able to swallow bourbon. He thinks he has lost approximately 15 lbs in the last year. He denies any blood in his stool and has not had any vomiting. The AGACNP knows that the most likely diagnosis is: A.Zenker’s diverticulum B. Achalasia C. Esophageal carcinoma D.Hiatal hernia Question 90 Mrs. Carpenter is a 59-year-old female who presents with an acute myocardial infarction. She is acutely short of breath and has coarse rales on auscultation. Physical examination reveals a grade V/VI systolic murmur, loudest at the point of maximal impulse with radiation to the midaxillary line. The AGACP recognizes: A. Acute mitral valve regurgitation B. Acute aortic valve regurgitation C. Acute cardiac tamponade D. Acute pulmonary embolus Question 91 Mr. Nelson is a 65-year-old male who has been advised that he is a candidate for coronary artery bypass grafting. He has been doing some internet research and is asking about whether or not he should have a “beating heart” bypass. Regarding off-pump coronary bypass grafting, the AGACNP advises Mr. Nelson that: A.There is a slightly higher risk of neurologic complications B. Long-term results suggest that the grafts do not stay open as long as those in traditional bypass grafting C. The incidence of off-pump bypass grafting has increased significantly in the last 10 years D.The off-pump procedure is considerably more expensive but is correlated with better long-term outcomes Question 92 Cholesteatoma is a condition characterized by a collection of desquamated keratin leading to bony erosion in the ossicular chain and inner ear. The goal of surgery in cholesteatoma is: A. Production of a dry ear B. Preservation of sensorineural hearing C. Debridement of infection D.Restoration of the tympanic membrane Question 93 The AGACNP is evaluating a patient who reportedly fell down a flight of steps. Her history is significant for several emergency room visits, but she denies any significant medical conditions. Some documentation in her chart indicates that she may have been subjected to physical abuse. Today she presents with a periorbital ecchymosis of the left eye and swelling in the left side of the face. Her neurologic examination is within normal limits. Which head imaging study would be most useful in assessing for findings consistent with a history of abuse? A. Radiographs B. CT scan without contrast C. MRI D. PET scan Question 94 R. R. is a 71-year-old female who presents with left lower quadrant pain that started out as cramping but has become more constant over the last day. She reports constipation over the last few days but admits that for as long as she can remember she has had variable bowel habits. Her vital signs are normal, but physical examination reveals some tenderness in the left lower quadrant. Which diagnostic test is most likely to support the leading differential diagnosis? A. CT scan with IV, oral, and rectal contrast B. CBC with WBC differential C. Colonoscopy D. Barium enema Question 95 The AGACNP knows that when managing a patient with acute cardiogenic shock after myocardial infarction, all of the following pharmacologic agents may be used except: A.Opioids B. Diuretics C. Beta-adrenergic antagonists D.Anticholinergics Question 96 According to the American College of Cardiology Foundation and the American Heart Association (ACCF/AHA), the recommendation regarding antiplatelet therapy in patients with cardiovascular disease preoperatively is that: A.Antiplatelet therapy should be held for 10 days preoperatively B. Cardiac consultation is required before an operation in patients who are on antiplatelet therapy C. Medications should be continued unless concerns about hemostasis are significant D.Antiplatelet therapy should be initiated in all high-risk cardiac procedures Question 97 The progression of coronary artery plaque formation can lead to a variety of pathologic conditions. When subtotal plaque disruption occurs resulting in vasoconstriction, platelet activation, and embolization, it most commonly causes which clinical phenomenon? A.Endothelial cell dysfunction B. Prinzmetal’s angina C. Transmural myocardial infarction D.Non-ST elevation myocardial infarction Question 98 D. is a 29-year-old male who presents with a chief complaint of profound dizziness for the past 2 to 3 days. Further clarification reveals that he is having brief but intense episodes of a sense of the room spinning. He denies any history of head injury or discharge from the ear. The vertigo is reproduced easily with cervical rotation. The AGACNP knows that the most likely cause is: A.Cerebral tumor B. Ménière’s disease C. Adverse drug effect D.Benign paroxysmal positional vertigo (BPPV) Question 99 According to the American College of Surgeons (ACS) and the National Surgical Quality Improvement Program (NSQIP) guidelines for preoperative evaluation of the geriatric patient, the preoperative evaluation should include all of the following except: A.Cognitive ability B. Functional status C. Competency assessment D. Frailty score Question 100 Which of the following statements is true with respect to adrenal tumors that produce gender symptoms? A. Feminizing adrenal tumors are almost always carcinomas B. Feminizing adrenal tumors are the most common type of adrenal tumor C. Virilizing tumors in women are most often localized to the adrenal cortex D. Virilizing adrenal tumors are more likely to be malignant in children