NURS 6531 MIDTERM EXAM - Complete Solution Package

NURS 6531 MIDTERM EXAM - Complete Solution Package -The most common cancer found on the auricle is: -Basal Cell Carcinoma -Which of the following medication classes should be avoided in patients with acute or chronic bronchitis because it will contribute to ventilation-perfusion mismatch in the patient? -Antihistamines -A 47-year-old male patient presents to the clinic with a single episode of a moderate amount of bright red rectal bleeding. On examination, external hemorrhoids are noted. How should the nurse practitioner proceed? -Refer the patient for a barium enema and sigmoidoscopy. -Which of the following patient characteristics are associated with chronic bronchitis? -Overweight, cyanosis, and normal or slightly increased respiratory rate -A 65-year-old female with a past medical history of hypertension, hyperlipidemia, and polymyalgia rheumatica presents to urgent care with new onset left lower quadrant pain. Her current medications include omeprazole 20 milligrams po daily, lisinopril 20 milligrams po daily, simvastatin 20 milligrams po daily, and prednisone 12 milligrams po daily. The nurse practitioner suspects acute diverticulitis and possibly an abscess. The most appropriate diagnostic test for this patient at this time is: -CT scan -A patient reports "something flew in my eye" about an hour ago while he was splitting logs. If there were a foreign body in his eye, the nurse practitioner would expect to find all except: -Purulent drainage -A 21-year-old college student presents to the student health center with copious, markedly purulent discharge from her left eye. The nurse practitioner student should suspect: -Gonococcal conjunctivitis -A 35-year-old man presents with radicular pain followed by the appearance of grouped vesicles consisting of about 15 lesions across 3 different thoracic dermatomes. He complains of pain, burning, and itching. The nurse practitioner should suspect: -Herpes zoster and consider that this patient may be immunocompromised -Which type of lung cancer has the poorest prognosis? -Small cell carcinoma -An 83-year-old female presents to the office complaining of diarrhea for several days. She explains she has even had fecal incontinence one time. She describes loose stools 3-4 times a day for several weeks and denies fever, chills, pain, recent antibiotic use. The history suggests that the patient has: -Chronic diarrhea -Margaret, age 32, comes into the office with painful joints and a distinctive rash in a butterfly distribution on her face. The rash has red papules and plaques with a fine scale. What do you suspect? -Systemic lupus erythematosus -Antibiotic administration has been demonstrated to be of little benefit to the treatment of which of the following disease processes? -Acute bronchitis -Lisa, age 49, has daily symptoms of asthma. She uses her inhaled short-acting beta-2 agonist daily. Her exacerbations affect her activities and they occur at least twice weekly and may last for days. She is affected more than once weekly during the night with an exacerbation. Which category of asthma severity is Lisa in? -Moderate persistent -Which of the following is the most appropriate therapeutic regimen for an adult patient with no known allergies diagnosed with group A B-hemolytic strep? -Penicillin V 500 milligrams PO every 8 hours for 10 days -A cashier complains of dull ache and pressure sensation in her lower legs. It is relieved by leg elevation. She occasionally has edema in her lower legs at the end of the day. What is the most likely cause of these problems? -Varicose veins -Which statement below is correct about pertussis? -It is also called whooping cough -Which of the following is the most important diagnosis to rule out in the adult patient with acute bronchitis? -Pneumonia -A 70 year old patient presents with left lower quadrant (LLQ) abdominal pain, a markedly tender palpable abdominal wall, fever, and leukocytosis. Of the following terms, which correctly describes the suspected condition? -Diverticulitis -Sylvia, age 83, presents with a 3-day history of pain and burning in the left forehead. This morning she noticed a rash with erythematous papules in that site. What do you suspect? -Herpes zoster -A 33-year-old female is admitted with acute pancreatitis. The nurse practitioner knows that the most common cause of pancreatitis is: -Gallstones -When a patient presents with symptoms of acute gallbladder disease, what is the appropriate nurse practitioner action? -Order an abdominal ultrasound -A false-positive result with the fecal occult blood test can result from: -a high dietary intake of rare cooked beef -A 76-year-old male complains of weight loss, nausea, vomiting, abdominal cramping and pain. Physical findings include an abdominal mass and stool positive for occult blood. The nurse practitioner pain suspects a tumor in the small intestine. The best diagnostic test for this patient is: -Small bowel follow-through -A patient presents to urgent care complaining of dyspnea, fatigue, and lower extremity edema. The echocardiogram reveals and ejection fraction of 38%. The nurse practitioner knows that these findings are consistent with: -Systolic heart failure -Maxine, Age 76, has just been given a diagnosis of pneumonia. Which of the following is an indication that she should be hospitalized? -Multi-lobar involvement on chest x-ray with the inability to take oral medications -A 55-year-old man is diagnosed with basal cell carcinoma. The nurse practitioner correctly tells him: - “It can be cured with surgical excision or radiation therapy." -Expected spirometry readings when the patient has chronic emphysema include: -Increased total lung capacity (TLC) -An 80-year-old male admits to difficulty swallowing during the review of systems. The nurse practitioner recognizes the differential diagnosis for this patient's dysphagia is: -Esophageal cancer and GERD -A 40 year old female with history of frequent sun exposure presents with a multicolored lesion on her back. It has irregular borders and is about 11mm in diameter. What should the nurse practitioner suspect? -Malignant melanoma -Which of the following is not a goal of treatment for the patient with cystic fibrosis? -Replace water-soluble vitamins -The nurse practitioner is performing a physical exam on a middle-aged African American man. Which of the following areas is a common site for melanomas in African Americans and other dark-skinned individuals? -nails and feet -An adult presents with tinea corporis. Which item below is a risk factor for its development? -Topical steroid use -A patient has experienced nausea and vomiting, headache, malaise, low grade fever, abdominal cramps, and watery diarrhea for 72 hours. His white count is elevated with a shift to the left. He is requesting medication for diarrhea. What is the most appropriate response? -Prescribe a broad-spectrum antibiotic such as ciprofloxacin (Cipro), and symptom management. -Janine, age 29, has numerous transient lesions that come and go, and she is diagnosed with urticaria. What do you order? -Antihistamines -Of the following signs and symptoms of congestive heart failure (CHF), the earliest clinical manifestation is: -Weight gain -A 16-year-old male presents with mild sore throat, fever, fatigue, posterior cervical adenopathy, and palatine petechiae. Without a definitive diagnosis for this patient, what drug would be least appropriate to prescribe? -Amoxicillin A 70-year-old man who walks 2 miles every day complains of pain in his left calf when he is walking. The problem has gotten gradually worse and now he is unable to complete his 2-mile walk. What question asked during the history, if answered affirmatively, would suggest a diagnosis of arteriosclerosis obliterans? -"Is your leg pain relieved by rest?" -Which of the following statements about malignant melanomas is true? -The prognosis is directly related to the thickness of the lesion -Sheila, age 78, presents with a chief complaint of waking up during the night coughing. You examine her and find an S3 heart sound, pulmonary crackles that do not clear with coughing, and peripheral edema. What do you suspect? -Heart Failure -Which antibiotic would be the most effective in treating community acquired pneumonia (CAP) in a young adult without any comorbid conditions? -Clarithromycin (Biaxin) -Which of the following dermatologic vehicles are the most effective in absorbing moisture and decreasing friction? -Powders -A 70 year old patient presents with a slightly raised, scaly, erythematous patch on her forehead. She admits to having been a "sun worshiper." The nurse practitioner suspects actinic keratosis. This lesion is a precursor to: -Squamous cell carcinoma -An elderly patient is being seen in the clinic for complaint of "weak spells" relieved by sitting or lying down. How should the nurse practitioner proceed with the physical examination? -Compare the patient's blood pressure lying first, then sitting, and then standing. -What oral medication might be used to treat chronic cholethiasis in a patient who is a poor candidate for surgery? -Ursodiol -A 46-year-old female with a past medical history of diabetes presents with a swollen, erythematous right auricle and is diagnosed with malignant otitis externa. The nurse practitioner knows that the most likely causative organism for this patient's problem is: -Pseudomonas aeruginosa -Which of the following is not a symptom of irritable bowel syndrome? -Weight loss -A patient comes in complaining of 1 week of pain in the posterior neck with difficulty turning the head to the right. What additional history is needed? -Any recent trauma -Marvin, age 56, is a smoker with diabetes. He has just been diagnosed as hypertensive. Which of the following drugs has the potential to cause the development of bronchial asthma and inhibit gluconeogenesis? -Beta Blocker -The differential diagnosis for a patient complaining of a sore throat includes which of the following? Gonococcal infection, Thrush, Leukoplakia -A patient presents to the primary care provider complaining of a rash on his right forehead that started yesterday and is burning and painful. The physical exam reveals an erythematous, maculopapular rash that extends over the patient's right eye to his upper right forehead. Based on the history and examination, the most likely cause of this patient's symptoms is: -Ophthalmic zoster -Before initiating an HMG CoA-reductase inhibitor for hyperlipidemia, the nurse practitioner orders liver function studies. The patient's aminotransferase (ALT) is elevated. What laboratory test(s) should be ordered? -Serologic markers for hepatitis -A patient with elevated lipids has been started on lovastatin. After 3 weeks of therapy, he calls to report generalized muscle aches. The nurse practitioner should suspect: -Rhabdomyolysis -Treatment of acute vertigo includes: -Bedrest and an antihistamine -Treatment of H.pylori includes which of the following? -Proton pump inhibitor, Antibiotic therapy, Bismuth subsalicylate -Carl, age 78, is brought to the office by his son, who states that his father has been unable to see clearly since last night. Carl reports that his vision is "like looking through a veil." He also sees floaters and flashing lights but is not having any pain. What do you suspect? -Retinal detachment -In order to decrease deaths from lung cancer: -Patients should be counseled to quit smoking -John, age 33, has a total cholesterol level of 188 mg/dL. How often should he be screened for hypercholesterolemia? -Every 5 years -Mort is hypertensive. Which of the following factors influenced your choice of using an alpha blocker as the antihypertensive medication? -Mort has benign prostatic hyperplasia -John, age 59, presents with recurrent, sharply circumscribed red papules and plaques with a powdery white scale on the extensor aspect of his elbows and knees. What do you suspect? -Psoriasis -Harriet, a 79-year-old woman, comes to your office every 3 months for follow up on her hypertension. Her medications include one baby aspirin daily, Lisinopril 5mg daily, and Calcium 1500 mg daily. At today's visit. Her blood pressure is 170/89. According to JNC VIII guidelines, what should you do next to control Harriet's blood pressure? -Add a thiazide diuretic to the Lisinopril 5mg daily -An active 65-year-old man under your care has known acquired valvular aortic stenosis and mitral regurgitation. He also has a history of infectious endocarditis. He has recently been told he needs elective replacement of his aortic valve. When he comes into the office you discover that he has 10 remaining teeth in poor repair. Your recommendation would be to: defer any further dental work until his valve replacement is completed -suggest he consult with his oral surgeon about having all the teeth removed at once and receiving appropriate antibiotic prophylaxis -Appropriate therapy for peptic ulcer disease (PUD) is: -Based on etiology Shirley, age 58, has been a diabetic for 7 years. Her blood pressure is normal. Other than her diabetes medications, what would you prescribe today during her routine office visit? -An ACE Inhibitor -Medicare is a federal program administered by the Centers for Medicare and Medicaid Services (CMS). The CMS has developed guidelines for Evaluation and Management coding, which all providers are expected to follow when coding patient visits for reimbursement. Which of the following is an important consideration regarding billing practices? -Failing to bill for billable services will lead to unnecessarily low revenues -A 2 year old presents with a white pupillary reflex. What is the most likely cause of this finding? -Retinoblastoma -Harvey has had Meniere's disease for several years. He has some hearing loss but now has persistent vertigo. What treatment might be instituted to relieve the vertigo? -A vestibular neurectomy -Which of the following is not a risk factor for coronary arterial insufficiency? -Alcohol ingestion -An 18-year-old female presents to the urgent care center complaining of severe pruritus in both eyes that started 2 days ago. Associated symptoms include a headache and fatigue. On examination, the nurse practitioner notes some clear discharge from both eyes and some erythema of the eyelids and surrounding skin. Which of the following is the most likely cause of this patient's symptoms? -Allergic conjunctivitis -A 20-year-old is diagnosed with mild persistent asthma. What drug combination would be most effective in keeping him symptom-free? -A bronchodilator PRN and an inhaled corticosteroid -Acute rheumatic fever is an inflammatory disease which can follow infection with: -Group A Streptococcus -A 60 year old male diabetic patient presents with redness, tenderness, and edema of the left lateral aspect of his face. His left eyelid is grossly edematous. He reports history of a toothache in the past week which "is better." His temperature is 100°F and pulse is 102 bpm. The most appropriate initial action is to: -Initiate a parenteral antibiotic and consider hospital admission -If a patient presents with a deep aching, red eye and there is no discharge, you should suspect: -Iritis -The National Cholesterol Education Program's Adult Treatment Panel III recommends that the goal for low density lipoproteins in high risk patients be less than: -100 mg/dL -A patient presents with classic symptoms of gastroesophageal reflux disease (GERD). He is instructed on lifestyle modifications and drug therapy for 8 weeks. Three months later he returns, reporting that he was "fine" as long as he took the medication. The most appropriate next step is: -Investigation with endoscopy, manometry, and/or pH testing -Group A β-hemolytic streptococcal (GABHS) pharyngitis is most common in which age group? -6 to 12 years of age -The most appropriate treatment for a child with mild croup is: -A cool mist vaporizer -A child complains that his "throat hurts" with swallowing. His voice is very "throaty" and he is hyperextending his neck to talk. Examination reveals asymmetrical swelling of his tonsils. His uvula is deviated to the left. What is the most likely diagnosis? -Peritonsillar abscess -Salmeterol (Servent) is prescribed for a patient with asthma. What is the most important teaching point about this medication? -It is not effective during an acute asthma attack. -Which intervention listed below is safe for long term use by an adult with constipation? -Bulk-forming agents -A 40-year-old presents with a hordeolum. The nurse practitioner teaches the patient to: -Apply a topical antibiotic and warm compresses. -Sarah has allergic rhinitis and is currently being bothered by nasal congestion. Which of the following meds ordered for allergic rhinitis would be most appropriate? -A decongestant nasal spray -What is the Gold standard for the diagnosis of asthma? -Spirometry -A patient complains of "an aggravating cough for the past 6 weeks." There is no physiological cause for the cough. Which medication is most likely causing the cough? -Enalapril -Stacy, age 27, states that she has painless, white, slightly raised patches in her mouth. They are probably caused by: -Candidiasis -Risk factors for acute otitis media (AOM) include all of the following except: -African-American ethnicity -Which of the following can result from chronic inflammation of a meibomian gland? -A chalazion What conditions must be met for you to bill "incident to" the physician, receiving 100% reimbursement from Medicare? -The physician must be on-site and engaged in patient care -Of the following choices, the least likely cause of cough is: -Acute pharyngitis -The most common correlate(s) with chronic bronchitis and emphysema is(are): -Cigarette smoking -Which choice below is least effective for alleviating symptoms of the common cold? - -When teaching a patient with hypertension about restricting sodium, you would include which of the following instructions? -Seventy-five of sodium intake is derived from processed foods -Which of the following heart murmurs warrants the greatest concern? -Diastolic murmur -A patient presents with an inflamed upper eyelid margin. The conjunctiva is red and there is particulate matter along the upper eyelid. The patient complains of a sensation that "there is something in my eye." What is the diagnosis and how should it be treated? -Blepharitis; treat with warm compresses and gentle debridement with a cotton swab -A 57-year-old male presents to urgent care complaining of substernal chest discomfort for the past hour. The EKG reveals ST elevations in Leads II, III, and AVF. The nurse practitioner is aware that these changes are consistent with which myocardial infarction territory? -Inferior wall -The nurse practitioner observes a tympanic membrane that is opaque, has decreased mobility, and is without bulging or inflammation. The least likely diagnosis for this patient is: -Acute otitis media (AOM) -Alan, age 54, notices a bulge in his midline every time he rises from bed in the morning. You tell him it is a ventral hernia, also known as: -epigastric hernia -A 58-year-old man is diagnosed with Barrett's esophagus after an endoscopy. He has no known allergies. Which of the following medications is MOST appropriate to treat this patient's disorder? -Omeprazole -Larry, age 66, is a smoker with hyperlipidemia and hypertension. He is 6 months post-MI. To prevent reinfarction, the most important behavior change that he can make is to: -Quit smoking -Risk factors for acute arterial insufficiency include which of the following? -Recent myocardial infarction, Atrial fibrillation, Atherosclerosis -Impetigo and folliculitis are usually successfully treated with: -Topical antibiotics NURS 6531 Spring 2019 Midterms Question 1 0 out of 1 points A patient has experienced nausea and vomiting, headache, malaise, low grade fever, abdominal cramps, and watery diarrhea for 72 hours. His white count is elevated with a shift to the left. He is requesting medication for diarrhea. What is the most appropriate response? **The main focus of treatment is to prevent dehydration by drinking plenty of fluids. In severe cases, hospitalization and intravenous fluids are necessary. Over-thecounter oral rehydration solutions (OHS), such as Pedialyte, can be helpful in mild cases Question 2 1 out of 1 points Which type of lung cancer has the poorest prognosis? Small cell carcinoma Question 3 1 out of 1 points Stacy, age 27, states that she has painless, white, slightly raised patches in her mouth. They are probably caused by: Candidiasis Question 4 1 out of 1 points An 80-year-old male admits to difficulty swallowing during the review of systems. The nurse practitioner recognizes the differential diagnosis for this patient’s dysphagia is: GERD & Cancer Question 5 1 out of 1 points A 40 year old presents with a hordeolum. The nurse practitioner teaches the patient to: apply a topical antibiotic and warm compresses. Question 6 1 out of 1 points Marvin has sudden eye redness that occurred after a strenuous coughing episode. You diagnose a subconjunctival hemorrhage. Your next step is to: Do nothing other than provide reassurance Isoniazid ppd Question 7 1 out of 1 points Which of the following is not a goal of treatment for the patient with cystic fibrosis? Replace water-soluble vitamins Question 8 0 out of 1 points The most common cancer found on the auricle is: **basal cell carcinoma** Question 9 1 out of 1 points Which of the following color changes in a pigmented lesion suggests malignant transformation? **ALL COLORS Question 10 1 out of 1 points Antibiotic administration has been demonstrated to be of little benefit to the treatment of which of the following disease processes? Acute bronchitis Question 11 1 out of 1 points The Centor criteria for diagnosis of Group A B-hemolytic streptococcus includes which of the following? A and B only Question 12 1 out of 1 points When teaching a patient with hypertension about restricting sodium, you would include which of the following instructions? Seventy-five of sodium intake is derived from processed foods Question 13 1 out of 1 points Mark has just been given a diagnosis of congestive heart failure. Which of his medications should be discontinued? Nifedipine (Procardia XL) for long-term management of his chronic stable angina. Question 14 1 out of 1 points Which of the following patient characteristics are associated with chronic bronchitis? overweight, cyanosis & normal or slighted increased resp. rate "blue bloaters" Question 15 1 out of 1 points Treatment of acute vertigo includes: -bedrest and an antihistamine Question 16 1 out of 1 points A 35 year old man presents with radicular pain followed by the appearance of grouped vesicles consisting of about 15 lesions across 3 different thoracic dermatomes. He complains of pain, burning, and itching. The nurse practitioner should suspect: herpes zoster and consider that this patient may be immunocompromised. Question 17 0 out of 1 points A 20 year old is diagnosed with mild persistent asthma. What drug combination would be most effective in keeping him symptom-free? **A bronchodilator PRN and an inhaled corticosteroid Question 18 0 out of 1 points Diagnosis of Crohn’s disease is made considering signs, symptoms and: **Intestinal obstruction demonstrated by plain x-ray of the abdomen Question 19 0 out of 1 points Which of the following is a predisposing condition for furunculosis? **Diabetes mellitus Question 20 1 out of 1 points Expected spirometry readings when the patient has chronic emphysema include: increased total lung capacity (TLC). Question 21 1 out of 1 points A child complains that his “throat hurts” with swallowing. His voice is very “throaty” and he is hyperextending his neck to talk. Examination reveals asymmetrical swelling of his tonsils. His uvula is deviated to the left. What is the most likely diagnosis? Peritonsillar abscess- my answer Question 22 0 out of 1 points Of the following signs and symptoms of congestive heart failure (CHF), the earliest clinical manifestation is: **weight gain. Question 23 1 out of 1 points Salmeterol (Servent) is prescribed for a patient with asthma. What is the most important teaching point about this medication? -It is not effective during an acute asthma attack Question 24 1 out of 1 points An active 65-year-old man under your care has known acquired valvular aortic stenosis and mitral regurgitation. He also has a history of infectious endocarditis. He has recently been told he needs elective replacement of his aortic valve. When he comes into the office you discover that he has 10 remaining teeth in poor repair. Your recommendation would be to: suggest that he consult with his oral surgeon about removing all the teeth at once and receiving appropriate antibiotic prophylaxis Question 25 1 out of 1 points A middle-aged male presents to urgent care complaining of fever, dysphagia, and shortness of breath. The nurse practitioner notes the patient leaning forward in a tripod position and drooling. The clinical presentation of this patient suggests: Epiglottitis Question 26 0 out of 1 points Alan, age 54, notices a bulge in his midline every time he rises from bed in the morning. You tell him it is a ventral hernia, also known as: **epigastric hernia Question 27 0 out of 1 points The differential diagnosis for a patient complaining of a sore throat includes which of the following? Thrush Question 28 1 out of 1 points Sheila, age 78, presents with a chief complaint of waking up during the night coughing. You examine her and find an S3 heart sound, pulmonary crackles that do not clear with coughing, and peripheral edema. What do you suspect? heart failure Question 29 1 out of 1 points The American Cancer Society recommends a flexible sigmoidoscopy for colorectal cancer screening in persons at average risk every: flexible sigmoidoscopy (FS) every 5 years, Question 30 1 out of 1 points Jennifer, age 49, who has a history of hyperlipidemia, has symptoms that lead you to suspect unstable angina. Your next action would be to: Hospitalize the client in a monitored setting with pharmacological control of ischemia, arrhythmias, and thrombosis as appropriate. Question 31 1 out of 1 points A 2 year old presents with a white pupillary reflex. What is the most likely cause of this finding? -Retinoblastoma Question 32 1 out of 1 points A patient presents to urgent care complaining of dyspnea, fatigue, and lower extremity edema. The echocardiogram reveals and ejection fraction of 38%. The nurse practitioner knows that these findings are consistent with: Systolic HF Question 33 1 out of 1 points John, age 33, has a total cholesterol level of 188 mg/dL. How often should he be screened for hypercholesterolemia? OFTEN Question 34 0 out of 1 points A 55 year old man is diagnosed with basal cell carcinoma. The nurse practitioner correctly tells him: **Basal cell carcinoma (BCC) is the most common type of skin cancer. It’s also the most commonly diagnosed cancer in the United States. Every year, millions of people learn that they have BCC. This skin cancer usually develops on skin that gets sun exposure, such as on the head, neck, or back of the hands. BCC is especially common on the face, often forming on the nose. While BCC often develops on skin that has had the most sun, BCC can appear on any part of the body, including the trunk, legs, and arms. People who use tanning beds also get BCC, and they also tend to get it earlier in life. This type of skin cancer grows slowly. It rarely spreads to other parts of the body. Treatment is important because BCC can grow wide and deep, destroying skin, tissue, and bone. Question 35 0 out of 1 points Your patient Jerry has gout. What do you suggest? **treating the acute attack of inflammation when one or more joints are very inflamed and painful ongoing treatment to reduce the level of urate in your blood and to get rid of urate crystals. The two most commonly used drug treatments for acute attacks of gout are nonsteroidal anti-inflammatory drugs (NSAIDs) and colchicine.Acute attacks of gout are often treated with oral non-steroidal anti-inflammatory drugs (NSAIDs), which can ease pain and possibly reduce some of the inflammation. Examples include ibuprofen, naproxen and etoricoxib. Question 36 1 out of 1 points Your well-nourished 75-year-old patient has come into the office for a physical exam and states that she recently had two nosebleeds. She does not take any anticoagulants, and you have ruled out any coagulopathies. The most likely cause of these nosebleeds is: Trauma or inflammation Question 37 1 out of 1 points A 33-year-old female is admitted with acute pancreatitis. The nurse practitioner knows that the most common cause of pancreatitis is: Gallstones Question 38 0 out of 1 points A 76-year-old male complains of weight loss, nausea, vomiting, abdominal cramping and pain. Physical findings include an abdominal mass and stool positive for occult blood. The nurse practitioner pain suspects a tumor in the small intestine. The best diagnostic test for this patient is: **Imaging tests used to diagnose small bowel cancer include: Computerized tomography (CT) scan. Magnetic resonance imaging (MRI) Positron emission tomography (PET) CBC, Blood chem, endoscopy, biopsy Question 39 1 out of 1 points Carl, age 78, is brought to the office by his son, who states that his father has been unable to see clearly since last night. Carl reports that his vision is “like looking through a veil.” He also sees floaters and flashing lights but is not having any pain. What do you suspect? Retinal Detachment Question 40 0 out of 1 points Management of a patient with hypertension and an abdominal aortic aneurysm would include: **The goals of pharmacotherapy are to reduce morbidity and to prevent complications. Antihypertensive agents are used to reduce tension on the vessel wall in patients with abdominal aortic aneurysms (AAAs) who have elevated blood pressure (BP). Esmolol (Brevibloc) View full drug information An ultrashort-acting beta1 blocker, esmolol is particularly useful in patients with elevated arterial pressure, especially if surgery is planned. It can be discontinued abruptly if necessary. This agent is normally used in conjunction with nitroprusside. It may be useful as a means of testing beta-blocker safety and tolerance in patients with a history of obstructive pulmonary disease who are at uncertain risk for bronchospasm from beta blockade. The elimination half-life of esmolol is 9 minutes. Labetalol (Trandate) View full drug information Labetalol blocks alpha1-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure. Propranolol (Inderal LA, InnoPran XL) View full drug information A class II antiarrhythmic nonselective beta-adrenergic receptor blocker, propranolol has membrane-stabilizing activity and decreases the automaticity of contractions. It is not suitable for emergency treatment of hypertension; it should not be administered IV in hypertensive emergencies. Metoprolol (Lopressor, Toprol-XL) View full drug information Metoprolol is a selective beta 1-adrenergic receptor blocker that decreases the automaticity of contractions. During IV administration, carefully monitor blood pressure, heart rate, and electrocardiograms. When considering conversion from IV to oral (PO) dosage forms, use the ratio of 2.5 mg PO to 1 mg IV. Nitroprusside (Nitropress) View full drug information Nitroprusside causes peripheral vasodilation by acting directly on venous and arteriolar smooth muscle, thus reducing peripheral resistance. This agent is commonly used IV because of its rapid onset and short duration of action. It is easily titrated to the desired effect. Because nitroprusside is light-sensitive, both bottle and tubing should be wrapped in aluminum foil. Before initiating nitroprusside therapy, administer a beta blocker to counteract the physiologic response of reflex tachycardia that occurs when nitroprusside is used alone. This physiologic response will increase the shear forces against the aortic wall, thus increasing dP/dt. The objective is to keep the heart rate between 60 and 80 beats/min. Morphine sulfate (Astramorph, Infumorph, Duramorph) Fentanyl citrate Question 41 1 out of 1 points Which of the following is not a symptom of irritable bowel syndrome? Symptoms are: Abdominal pain, cramping or bloating that is typically relieved or partially relieved by passing a bowel movement Excess gas Diarrhea or constipation — sometimes alternating bouts of diarrhea and constipation Weight loss Diarrhea at night Rectal bleeding Iron deficiency anemia Unexplained vomiting Difficulty swallowing Persistent pain that isn't relieved by passing gas or a bowel movement Mucus in the stool Question 42 1 out of 1 points Impetigo and folliculitis are usually successfully treated with: Topical antibiotics Question 43 1 out of 1 points Which of the following is not a risk factor for coronary arterial insufficiency? Risks are: Older age: Over age 45 years in men and over age 55 years in women Family history of early heart disease Race: Among persons with CAD, the cardiovascular death rate for African Americans is reported to be particularly high; in Asians, low levels of high-density lipoprotein cholesterol (HDL-C), which are considered to be a risk factor for coronary heart disease, appear to be especially prevalent; South Asians appear to have a higher independent risk for cardiovascular disease as well. High blood cholesterol levels (specifically, low-density lipoprotein cholesterol [LDLC]) High blood pressure Cigarette smoking: Cessation of cigarette smoking constitutes the single most important preventive measure for CAD Diabetes mellitus [1] Obesity Lack of physical activity Metabolic syndrome Mental stress and depression Question 44 1 out of 1 points The most appropriate treatment for a child with mild croup is: a cool mist vaporizer. Question 45 1 out of 1 points John, age 59, presents with recurrent, sharply circumscribed red papules and plaques with a powdery white scale on the extensor aspect of his elbows and knees. What do you suspect? psoriasis. Question 46 1 out of 1 points Appropriate therapy for peptic ulcer disease (PUD) is: **In general, 6-8 weeks of therapy with a PPI is required for complete healing of a duodenal ulcer. Active ulcers associated with NSAID use are treated with an appropriate course of PPI therapy and the cessation of NSAIDs.Eradication of H. pylori is recommended in all patients with PUD Based on etiology Question 47 1 out of 1 points An AST that is more than twice the level of ALT is suggestive of: **alcoholic liver disease, Question 48 1 out of 1 points A 45 year old with diabetes has had itching and burning lesions between her toes for 2 months. Scrapings of the lesions confirm the diagnosis tinea pedis. What is the best initial treatment option for this patient? Prescribe an anti-fungal powder for application between her toes and in her shoes and a topical prescription strength anti-fungal cream for other affected areas. Monitor for a secondary bacterial infection. Question 49 0 out of 1 points An elderly patient is being seen in the clinic for complaint of “weak spells” relieved by sitting or lying down. How should the nurse practitioner proceed with the physical examination? Question 50 1 out of 1 points Sandra has celiac disease. You place her on which diet? Gluten-free Question 51 1 out of 1 points Larry, age 66, is a smoker with hyperlipidemia and hypertension. He is 6 months post-MI. To prevent reinfarction, the most important behavior change that he can make is to: Quit smoking Question 52 1 out of 1 points Group A -hemolytic streptococcal (GABHS) pharyngitis is most common in which β age group? 6-12 Question 53 0 out of 1 points A very active elderly patient has a documented diagnosis of arteriosclerosis obliterans. Common expected lower extremity physical exam findings include: ** Question 54 1 out of 1 points Which of the following is a secondary cause of hyperlipidemia? Diabetes mellitus **Diet: excessive intake of saturated fat and/or calories, alcohol consumption, anorexia Drugs: diuretics, beta-blockers, cyclosporine, estrogen, glucocorticoids, anabolic steroids, retinoids, protease inhibitors Disease: chronic liver disease, primary biliary cirrhosis, chronic renal failure, nephrotic syndrome, Cushing’s syndrome, systemic lupus erythematosus Dysmetabolism: hypothyroidism, diabetes, obesity, insulin resistance Question 55 0 out of 1 points Harvey has had Meniere’s disease for several years. He has some hearing loss but now has persistent vertigo. What treatment might be instituted to relieve the vertigo? a vestibular neurectomy Question 56 1 out of 1 points An employee picnic menu includes grilled hamburgers, potato salad, and homemade ice cream sundaes. Within an hour after the meal, several children and parents begin to have nausea, vomiting and stomach cramps. None of those affected have fever. What is the most likely etiologic agent? Staphylococcus aureus Question 57 0 out of 1 points The nurse practitioner is performing a physical exam on a middle-aged AfricanAmerican man. Which of the following areas is a common site for melanomas in African-Americans and other dark-skinned individuals? The most common site of melanoma in African Americans is the feet, with 60% of patients having subungual or plantar lesions Question 58 0 out of 1 points A 58-year-old man is diagnosed with Barrett’s esophagus after an endoscopy. He has no known allergies. Which of the following medications is MOST appropriate to treat this patient’s disorder? ***Periodic endoscopy to monitor the cells in your esophagus. If your biopsies show no dysplasia, you'll probably have a follow-up endoscopy in one year and then every three years if no changes occur. Treatment for GERD. Medication and lifestyle changes can ease your signs and symptoms. Surgery to tighten the sphincter that controls the flow of stomach acid may be an option. Treating GERD doesn't treat the underlying Barrett's esophagus and likely won't decrease the risk of esophageal cancer, but can help make it easier to detect dysplasia. Endoscopic resection, which uses an endoscope to remove damaged cells. Radiofrequency ablation, which uses heat to remove abnormal esophagus tissue. Radiofrequency ablation may be recommended after endoscopic resection. Cryotherapy, which uses an endoscope to apply a cold liquid or gas to abnormal cells in the esophagus. The cells are allowed to warm up and then are frozen again. The cycle of freezing and thawing damages the abnormal cells. Photodynamic therapy, which destroys abnormal cells by making them sensitive to light. Surgery in which the damaged part of your esophagus is removed, and the remaining portion is attached to your stomach Question 59 1 out of 1 points Shirley, age 58, has been a diabetic for 7 years. Her blood pressure is normal. Other than her diabetes medications, what would you prescribe today during her routine office visit? An ACE inhibitor Question 60 1 out of 1 points A 70 year old patient presents with a slightly raised, scaly, erythematous patch on her forehead. She admits to having been a “sun worshiper.” The nurse practitioner suspects actinic keratosis. This lesion is a precursor to: squamous cell carcinoma. Question 61 0 out of 1 points A patient presents to the office with a blood pressure 142/80. This patient is classified as having: HB stage 1 High Blood Pressure (Hypertension) Stage 1 Systolic: From 140 to 159 Diastolic: From 90 to 99 High Blood Pressure (Hypertension) Stage 2 Systolic: 160 or higher Diastolic: 100 or higher Hypertensive Crisis (Emergency care needed) Systolic: Higher than 180 Diastolic: Higher than 110 Question 62 1 out of 1 points Which of the following is the most appropriate therapeutic regimen for an adult patient with no known allergies diagnosed with group A B-hemolytic strep? Penicillin Question 63 1 out of 1 points A patient reports “something flew in my eye” about an hour ago while he was splitting logs. If there were a foreign body in his eye, the nurse practitioner would expect to find all except: A purulent discharge. Question 64 0 out of 1 points A patient complains of “an aggravating cough for the past 6 weeks.” There is no physiological cause for the cough. Which medication is most likely causing the cough? ** This class is called the ACE inhibitors. Some examples of ACE inhibitors include lisinopril, captopril, and ramipril. The cough is generally a dry one but can be quite annoying. 99 erick ** enalapril? Question 65 0 out of 1 points Which choice below is least effective for alleviating symptoms of the common cold? antibiotics liberal intake of fluids adequate rest Aspirin warm clothing Question 66 0 out of 1 points An 83-year-old female presents to the office complaining of diarrhea for several days. She explains she has even had fecal incontinence one time. She describes loose stools 3–4 times a day for several weeks and denies fever, chills, pain, recent antibiotic use. The history suggests that the patient has: ** Question 67 0 out of 1 points A patient reports to the nurse practitioner that he was diagnosed with hepatitis B a year ago and has not seen a health care provider since then. What information should this patient be given? About 10% of affected persons become carriers and are at increased risk for hepatocellular carcinoma. Question 68 1 out of 1 points The most common correlate(s) with chronic bronchitis and emphysema is(are): Smoking Question 69 1 out of 1 points If a patient presents with a deep aching, red eye and there is no discharge, you should suspect: Iritis Question 70 1 out of 1 points Treatment of H.pylori includes which of the following? Proton pump inhibitor Antibiotic therapy Bismuth subsalicylate A and B A, B, and C my answer Question 71 1 out of 1 points Which of the following is the most important diagnosis to rule out in the adult patient with acute bronchitis? pneumonia Question 72 1 out of 1 points What oral medication might be used to treat chronic cholethiasis in a patient who is a poor candidate for surgery? Certain chemicals, such as ursodiol or chenodiol, Question 73 1 out of 1 points Which of the following best describes hypertrophic cardiomyopathy? of heart disease that affects the heart muscle. It causes thickening of the heart muscle (especially the ventricles, or lower heart chambers), left ventricular stiffness, mitral valve changes and cellular changes. Question 74 1 out of 1 points Amaurosis fugax is described as a: is a painless temporary loss of vision in one or both eyes. Transient and periodic Question 75 1 out of 1 points The nurse practitioner observes a tympanic membrane that is opaque, has decreased mobility, and is without bulging or inflammation. The least likely diagnosis for this patient is: **? A common cause of conductive hearing loss in adults ages 20 - 40 is otosclerosis, a gradual hardening of the tympanic membrane that causes the footplate of the stapes to become fixed in the oval window. Presbycusis, a progressive, bilaterally symmetrical perceptive hearing loss arising from structural changes in the hearing organs, usually occurs after age 50. Trauma may result in a conductive hearing loss, but this is certainly not common. Question 76 0 out of 1 points Which of the following heart murmurs warrants the greatest concern? ** Murmurs that occur during diastole are NEVER INNOCENT and should always raise concern and indicate further investigation Question 77 0 out of 1 points A patient with elevated lipids has been started on lovastatin. After 3 weeks of therapy, he calls to report generalized muscle aches. The nurse practitioner should suspect: Rhabdomyolysis- Drug interaction Question 78 0 out of 1 points Harriet, a 79-year-old woman, comes to your office every 3 months for follow up on her hypertension. Her medications include one baby aspirin daily, Lisinopril 5mg daily, and Calcium 1500 mg daily. At today’s visit. Her blood pressure is 170/89. According to JNC VIII guidelines, what should you do next to control Harriet’s blood pressure? (HTN stage 2) ***First-line and later-line treatments should now be limited to 4 classes of medications: thiazide-type diuretics, calcium channel blockers (CCBs), ACE inhibitors, and ARBs. • Second- and third-line alternatives included higher doses or combinations of ACE inhibitors, ARBs, thiazide-type diuretics, and CCBs. Several medications are now designated as later-line alternatives, including the following: beta-blockers, alphablockers, alpha1/beta-blockers (eg, carvedilo), vasodilating beta-blockers (eg, nebivolol), central alpha2/-adrenergic agonists (eg, clonidine), direct vasodilators (eg, hydralazine), loop diruretics (eg, furosemide), aldosterone antagoinsts (eg, spironolactone), and peripherally acting adrenergic antagonists (eg, reserpine). ACE inhibitors and ARBs should not be used in the same patient simultaneously. • CCBs and thiazide-type diuretics should be used instead of ACE inhibitors and ARBs in patients over the age of 75 years with impaired kidney function due to the risk of hyperkalemia, increased creatinine, and further renal impairment. Question 79 0 out of 1 points Of the following, the patient who should be referred for periodic colonoscopy is the patient with: Question 80 0 out of 1 points Dana has ischemic arterial ulcers. What is your first priority when counseling her? Tell her to reduce risk factors to improve tissue perfusion Question 81 1 out of 1 points After thorough history, physical examination, and laboratory tests, a patient is diagnosed with irritable bowel syndrome (IBS). Which of the following initial treatment plans is currently considered most effective? A low fat, tyramine-free, caffeine-free, high fiber diet, along with a daily diary, and attention to psychosocial factors. Question 82 1 out of 1 points Margaret, age 32, comes into the office with painful joints and a distinctive rash in a butterfly distribution on her face. The rash has red papules and plaques with a fine scale. What do you suspect? SLE Question 83 1 out of 1 points What is the Gold standard for the diagnosis of asthma? Spirometry Question 84 0 out of 1 points An 8 year old presents to the health clinic with history of acute onset severe sore throat and respiratory distress with stridor in the last 2 hours. The child’s history is positive for fever and pharyngitis for 2 days. What is the most likely diagnosis? croup Question 85 0 out of 1 points The National Cholesterol Education Program’s Adult Treatment Panel III recommends that the goal for low density lipoproteins in high risk patients be less than: goal of less than 100 mg/dL with statin treatments in managed care patients at high risk for coronary heart disease Question 86 0 out of 1 points Which intervention listed below is safe for long term use by an adult with constipation? **bulk-forming laxatives, also referred to as fiber supplements, are the gentlest on your body and safest to use long term. Metamucil and Citrucel fall into this category Question 87 1 out of 1 points The nurse practitioner is reviewing a patient’s lab report who completed the hepatitis B series 3 months ago. Which of the following lab results would you expect to see in this patient? Positive hepatitis B surface antibody and negative core antibody- my answer Question 88 0 out of 1 points Sarah has allergic rhinitis and is currently being bothered by nasal congestion. Which of the following meds ordered for allergic rhinitis would be most appropriate? OTC oral antihistamines such as loratadine, cetirizine, fexofenadine, desloratadine, levocetirizine, and diphenhydramine. These medications are most effective at decreasing rhinorrhea, nasal itching, and sneezing. Question 89 0 out of 1 points A cashier complains of dull ache and pressure sensation in her lower legs. It is relieved by leg elevation. She occasionally has edema in her lower legs at the end of the day. What is the most likely cause of these problems? superficial venous insufficiency (SVI) or deep venous insufficiency (DVI), and to a lesser extent peripheral artery disease (PAD). Question 90 0 out of 1 points A 46-year-old female with a past medical history of diabetes presents with a swollen, erythematous right auricle and is diagnosed with malignant otitis externa. The nurse practitioner knows that the most likely causative organism for this patient’s problem is: Pseudomonas aeruginosa, Question 91 0 out of 1 points A 60 year old male diabetic patient presents with redness, tenderness, and edema of the left lateral aspect of his face. His left eyelid is grossly edematous. He reports history of a toothache in the past week which “is better.” His temperature is 100°F and pulse is 102 bpm. The most appropriate initial action is to: ** Question 92 0 out of 1 points A 57-year-old male presents to urgent care complaining of substernal chest discomfort for the past hour. The EKG reveals ST elevations in Leads II, III, and AVF. The nurse practitioner is aware that these changes are consistent with which myocardial infarction territory? acute inferior myocardial infarction -occurs when inferior myocardial tissue supplied by the right coronary artery, or RCA, is injured due to thrombosis of that vessel. Question 93 0 out of 1 points Which of the following can result from chronic inflammation of a meibomian gland? Blepharitis Dry eye syndrom Stasis, loss of function of glands Question 94 0 out of 1 points A 15 year old male presents with abdominal pain that began in the peri-umbilical area then localized to the right lower quadrant (RLQ). He complains of anorexia, and low grade fever. A complete blood count (CBC) reveals moderate leukocytosis. What is the most likely diagnosis? Acute appendicitis Question 95 0 out of 1 points Which of the following medication classes should be avoided in patients with acute or chronic bronchitis because it will contribute to ventilation-perfusion mismatch in the patient? Question 96 0 out of 1 points A false-positive result with the fecal occult blood test can result from: a high dietary intake of rare cooked beef -my answer Question 97 0 out of 1 points A patient presents with classic symptoms of gastroesophageal reflux disease (GERD). He is instructed on life style modifications and drug therapy for 8 weeks. Three months later he returns, reporting that he was “fine” as long as he took the medication. The most appropriate next step is: ** Question 98 0 out of 1 points Risk factors for acute arterial insufficiency include which of the following? Question 99 0 out of 1 points A patient presents to the primary care provider complaining of a rash on his right forehead that started yesterday and is burning and painful. The physical exam reveals an erythematous, maculopapular rash that extends over the patient’s right eye to his upper right forehead. Based on the history and examination, the most likely cause of this patient’s symptoms is: OPthalmic zoster Question 100 0 out of 1 points Which of the following are classic features of ulcerative colitis? Signs and symptoms include bloody diarrhea, abdominal cramps and pain, and an inability to move the bowels in spite of the urge to do so (tenesmus). Left-sided colitis. Inflammation extends from the rectum up through the sigmoid and descending colon. A 40 year old female with history of frequent sun exposure presents with a multicolored lesion on her back. It has irregular borders and is about 11 mm in diameter. What should the nurse practitioner suspect? A. Squamous cell carcinoma B. Malignant melanoma C. Common nevus D. Basal cell carcinomaB A client comes in complaining of 1 week of pain in the posterior neck with difficulty turning the head to the right. What additional history is needed? A. Recent trauma B. Difficulty swallowing C. Stiffness in the right shoulder D. Change in sleeping habitsRecent Trauma What prophylactic medication is commonly recommended for the patient under 35 years of age with a positive PPD? Ethambutol Streptomycin Pyrazinamide Isoniazid (INH) An adult presents with tinea corporis. Which item below is a risk factor for its development? Topical steroid use* Topical antibiotic use A recent laceration Cold climates 67. A 55 year old patient has a work-up for hypertension and is noted to have elevated BUN and creatinine. Which of the following should the nurse practitioner suspect? Pheochromocytoma Renal disease Diabetes * Dehydration 68 A 16 year old male presents with mild sore throat, fever, fatigue, posterior cervical adenopathy, and palatine petechiae. Without a definitive diagnosis for this patient, what drug would be least appropriate to prescribe? Ibuprofen* Erythromycin Amoxicillin Acetaminophen 75 erick management or hypertension Elizabeth, age 83, presents with a 3-day history of pain and burning in the left forehead. This morning she noticed a rash with erythematous papules in that site. You suspect: a varicella. B herpes zoster. C. syphilis. D. rubella. b 80 jerry gout salicylates 84 Janine, age 29, has numerous transient lesions that come and go, and she is diagnosed with urticaria. What do you order? Aspirin NSAIDs Opioids Antihistamines 86 Which of the following can result from chronic inflammation of a meibomian gland? A chalazion Uveitis Keratitis A pterygium 87 A 58 year old complains of tightness in his chest while cutting firewood. It disappears quickly if he stops chopping. He denies shortness of breath, his total cholesterol level is less than 200 mg/dL, and he is a non-smoker. What is the most appropriate action for the nurse practitioner to take with this patient? Treat the complaints as “cardiac” in origin until proven otherwise. ** Consider a gastrointestinal workup to rule out GERD. Consider arthritis and order chest and spinal xrays. Encourage the patient to chop fewer pieces of wood at a time. Lisa, age 49, has daily symptoms of asthma. She uses her inhaled short-acting beta-2 agonist daily. Her exacerbations affect her activities and they occur at least twice weekly and may last for days. She is affected more than once weekly during the night with an exacerbation. Which category of asthma severity is Lisa in? Mild intermittent Mild persistent Moderate persistent ** 92 Risk factors for acute otitis media (AOM) include all of the following except: Household cigarette smok Group daycare attendance Sibling history of acute otitis media African-American ethnicity** 94 Which antibiotic would be the most effective in treating community acquired pneumonia (CAP) in a young adult without any comorbid conditions? Erythromycin Clarithromycin (Biaxin) Doxycycline (Vibramycin) Penicillin** NURS 6531 Midterm Exam Review (Week 1-6) **Save for Final comprehensive Exam Review** Competencies of Advanced Nurse Practitioners HOW TO APPLY ADVANCED PRACTICE NURSING COMPETENCIES TO CLINICAL SETTINGS With the growth in Advanced Practice Roles such as the Clinical Nurse Specialist and Nurse Practitioner titles there is more recognition and interest in the potential benefits that APNs may bring to the care of patients. Numerous studies have shown the value of using advanced practice nurses in the clinical setting yielding significant contributions and examples of outcome measures for APNs. APNs are effective in improving the outcomes such as patient satisfaction, readmissions, cost, health status, and complications. The interprofessional educational efforts should instill the core competencies by following guiding principles of being patient centered; having a community or population focus; emphasizing relationships and processes; containing developmentally appropriate activities and assessments; and being outcome driven. The American Nurses Association (ANA) 20 issued a competency document outlining essential genomic competencies for graduate nurses. The document was established by an expert consensus panel in genetics and genomics. The document contains 38 competencies under seven major categories that include risk assessment and interpretation; genetic education, counseling, testing, and results interpretation; clinical management; ethical, legal, and social implications; professional role; leadership; and research. In professional practice, the essential competencies of the ANA document require nurses with graduate level education to be competent in risk assessment and interpretation; genetic education, counseling, testing, and results interpretation; clinical management; and ethical, legal, and social implications as they relate to genetics and genomics. Theories in nursing practice (See the last page-split among many members-most have not submitted) SOAP NOTE – S – Looking for Subjective Evidence Interview the patient and/or family member about the history of the present illness. Ask about the presentation of the illness (timing, signs and symptoms, etc.) Ask whether the patient is on any medication, inquire about past medical history, diet, etc. Be alert for the historical findings because they provide important clues that help point to the correct diagnosis (or differential diagnosis). O - Looking for Objective Evidence Perform physical exam (general or targeted to the present complaints). If applicable, perform a physical maneuver (Tinel’s, Kernig’s, drawer, etc.) Order laboratory/other tests to “rule in” (or “rule out”) the differential diagnosis If the laboratory test result is abnormal, you may be asked about the next step (such as a follow up lab test that is more sensitive or specific). A-Assessment The medical diagnoses for the medical visit on the given date of a note written. An assessment is the diagnosis or condition the patient has. In some instances, there may be one clear diagnosis. In other cases, a patient may have several things wrong. There may also be other times where a definitive diagnosis is not yet made, and more than one possible diagnosis is included in the assessment. P-Plan This describes what the health care provider will do to treat the patient - ordering labs, referrals, procedures performed, medications prescribed, etc. How you are going to address the patient’s problem. It may involve ordering additional tests to rule out or confirm a diagnosis. It may also include treatment that is prescribed, such as medication or surgery. The plan may also include information for self-care and deposition including bed rest and days off work. CODING AND BILLING PRACTICES FOR NP’S. For reimbursement of services the first thing that has to happen is the NP needs to obtain a National Provider Identifier (NPI) number. This application is online. You also will need to apply/enroll as a Medicare and Medicaid provider (separate applications) using that NPI number. Billing: When you have all your appropriate billing numbers you can submit for reimbursement. NPs can bill under their own numbers and reimbursement will be at 85% of the physician fee schedule for outpatient and inpatient services. “Incident to services” is a billing term specific to Medicare for the office/outpatient setting. When NPs bill “incident to”, they are reimbursed at 100% of the physician fee. These instances have specific requirements. #1 The services must in rendered in the physician’s office under “Physician’s direct personal supervision”. This means that the physician must be available on site to provide assistance if needed. It does NOT mean that the physician has to see the patient on that visit or that they must “sign off” on that patient’s visit. The physician DOES have to do the initial visit and see the patient on a frequency that supports that he/she is involved in the patient’s plan of care. “Incident to” does not apply in the hospital setting. Split/Shared E/M Services applies to hospital inpatient/hospital outpatient or emergency department. This is used when BOTH the NP and physician have BOTH had a face to face visit with the patient. The key here is Face to Face. Doctor must physically lay eyes on the patient, not just review documentation. Other third party payers vary on reimbursement from 85-100%. Coding: is based on the complexity of the visit. E/M Coding represents the health care provider’s cognitive skills and includes office or clinic visits, consultations, preventative medical examinations, and critical care services. Make sure codes are accurate for diagnoses as Over AND Under coding both constitute Medicare fraud. Medicare fraud can result in fines, criminal prosecution, loss of provider status and license. Other key points I found: “collaborative” does not mean “supervisory”. In Home Health services, physicians must complete medical necessity eval. NP’s cannot bill for Medicare under Medicare A “Delegation from a physician”. Under part B, NP’s can bill provided services are “physician services” i.e. Dx, Tx, consult, care plan management. NP’s can be reimbursed for all care “evaluation and management codes” and diagnostic tests if in collaboration with MD. INTEGUMENTARY DISORDERS MELANOMA Differential diagnoses a. actinic keratosis b. seborrheic keratosis c. dysplastic nevi d. basal or squamous cell carcinoma Various treatment options a. surgical biopsy or removal b. lymph node excision c. chemotherapy/immunotherapy Pattern recognition a. usual age for diagnosis is early 40s b. abcde (asymmetry, border irregularity, color variation, diameter 6mm, elevation above level of skin) c. hypo or hyperpigmentation, bleeding, scaling, or size change of existing mole or lesion d. common in caucasians on back, anterior lower leg e. common in african-americans on nails, hands, and feet Comments/suggestions/additional information: Accounts for over 65% of skin cancer deaths; metastasizes to any organ. ACTINIC KERATOSIS Differential diagnoses a. seborrheic keratosis b. warty lesions c. solar lentigo d. malignant melanoma e. basal cell or squamous cell carcinoma Various treatment options a. liquid nitrogen by a freeze-thaw technique to obtain a 1-to-3mm rim of freeze, allowing slow thawing during 20 to 40 seconds b. topical fluorouracil cream c. topical imiquimod 5% cream d. photodynamic therapy (using topical & light therapy) e. tca peels f. tretinoin 0.02-0.1% or salicylic acid 6% in addition to topical imiquimod cream can enhance treatment Pattern recognition a. round, oval shaped scaly lesions b. flesh colored, red, pink, brown, or black c. may be papules or plaques and are rough when palpated d. size varies from 0.25-2.0cm; usually 1cm BASAL CELL CARCINOMA Differential diagnoses a. actinic keratosis b. seborrheic keratosis c. dysplastic nevi d. melanoma or squamous cell Various treatment options a. electrodesiccation & currettage b. surgical biopsy &/or removal Pattern recognition a. common in 40-60 year olds but increasing incidence in younger age groups b. males more common than females c. most common sites are head and neck (80% of cases… 20% on lower extremeties) d. common appearance is pearly domed nodule with overlying telangiectatic vessels; may vary from flesh colored to slightly pigmented lesion e. may be plaque, papule, or may see central ulceration and crusting later on Comments/Suggestions/Additional Information: an annual skin examination is recommended for those diagnosed with basal cell carcinoma; a physician or dermatologist can do this exam. SQUAMOUS CELL CARCINOMA Differential diagnoses A. Actinic keratosis B. basal cell carcinoma C. common warts D. prurigo nodularis Various treatment options A. Cryotherapy (liquid nitrogen applied to the tumor either via spray gun or direct contact. B. electrodessication/curretage C. photodynamic therapy (a topical photosensitize therapy such as 5-aminoleculinic acid) Pattern recognition A. actinic keratosis: precursor lesions to SCC- physical assessment shows scaly growth caused by damage from exposure to ultraviolet (UV) radiation- The rough, scaly skin patch enlarges slowly and usually causes no other signs or symptoms. B. SCC in situ (Bowens disease): slowly enlarging, erythematous, well-demarcated scaly patch or plaque and confined to outer layer of skin C. Invasive SCC: spread into deeper layers of skin D. Metastatic SCC: spread to