NURS 6560 MIDTERM EXAM – QUESTION AND ANSWERS. (GOLD LEVEL EXPERT RECOMMENDS) DOWNLOAD TO SCORE A+

NURS 6560 MIDTERM EXAM – QUESTION AND ANSWERS Question 1 S. is a 59-year-old female who has been followed for several years for aortic regurgitation. Serial echocardiography has demonstrated normal ventricular function, but the patient was lost to follow-up for the last 16 months and now presents complaining of activity intolerance and weight gain. Physical examination reveals a grade IV/VI diastolic aortic murmur and 2+ lower extremity edema to the midcalf. The AGACNP considers which of the following as the most appropriate management strategy? A. Serial echocardiography every 6 months B. Begin a calcium channel antagonist C. Begin an angiotensin converting enzyme (ACE) inhibitor D. Surgical consultation and intervention C. Begin an angiotensin converting enzyme (ACE) inhibitor The patient is having grade 6 diastolic aortic murmur. The murmur is not accompanied by any serious complications because there is a 2+ lower extremity edema to the midcalf. Angiotensin converting enzyme (ACE) inhibitor lowers the blood pressure. High blood pressure often worsens the underlying conditions that cause heart murmurs. Beginning an angiotensin converting enzyme (ACE) inhibitor will help in the management of diastolic aortic murmur by dealing with the conditions that cause heart murmurs. A surgery would be used only when the valves are damaged or leaky Reference Question 2 An ascending thoracic aneurysm of 5.5 cm is universally considered an indication for surgical repair, given the poor outcomes with sudden rupture. Regardless of the aneurysm’s size, all of the following are additional indications for immediate operation except: A. Comorbid Marfan’s syndrome B. Enlargement of 1 cm since diagnosis C. Crushing chest pain D. History of giant cell arteritis C. crushing chest pain Prophylactic surgery is recommended when the aorta reaches a diameter of 5.5 cm, when the patient falls under the Marfan syndrome bicuspid aortic valve category, when the enlargement is greater than 0.5 cm, and when the patient has a history of fast-growing cell arteritis. Marfan syndrome is a connective tissue condition that involves the respiratory, skeletal, cardiovascular and ocular systems. It is one of the most serious complication of aortic valve regurgitations and needs an immediate surgery. For this reason, a crushing chest pain is the odd one out Reference Question 3 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 B. CT Scan of the neck Deep neck space infection may lead to severe and potentially life-threatening complications, such as airway obstruction, mediastinitis, septic embolization, dural sinus thrombosis, and intracranial abscess. In the evaluation of these infections, ultrasonography is the gold standard: 1. to differentiate abscesses from cellulitis 2. for the diagnosis of lymphadenitis However, field-of-view limitation and poor anatomical information confine the use of ultrasonography to the evaluation of superficial lesions and to image-guided aspiration or drainage. Computed tomography (CT) combines fast image acquisition and precise anatomical information without field-of-view limitations. For these reasons, it is the most reliable technique for the evaluation of deep and multi-compartment lesions REFERENCE Question 4 Mr. Draper is a 39-year-old male recovering from an extended abdominal procedure. As a result of a serious motor vehicle accident, he has had repair of a small bowel perforation, splenectomy, and repair of a hepatic laceration. He will be on total parenteral nutrition postoperatively. The AGACNP recognizes that the most common complications of parenteral nutrition are a consequence of: A. Poorly calculated solution B. Resultant diarrhea and volume contraction C. The central venous line used for infusion D. Bowel disuse and hypomotility C. The central venous line used for infusion Total parenteral nutrition is the administration of nutritional components via the venous system rather than the enteral route/gastrointestinal tract. It can be total or partial where just a selected number of nutrients are given This type of nutrient administration comes with a myriad of challenges as a result of the many complications associated with it. Among the complications the most common is infection which commonly results from the central venous line used. The contamination of the blood stream is with normal skin flora around the cannulation site, commonly staphylococcus organisms The other complications include: 1. Dehydration and electrolyte Imbalances due to inadequate intake 2. Venous thrombosis 3. Hyperglycemia (high blood sugars) 4. Hypoglycemia (low blood sugars) 5. Micro-nutrient deficiencies (vitamin and minerals) Question 5 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 B. 25-50% Having one pneumothorax increases the chances for a second and third. Mr. Mettenberger has been discharge but no surgical intervention was employed to reduce the odds for a second. He was hospitalized for expansion of his second spontaneous pneumothorax. While he has stopped smoking and does not appear to have any overt risk factors, there is still a 25-50% likelihood of having a third attack because there is no surgical intervention. His current risk for another pneumothorax is 25-50% Reference Question 6 One of the earliest findings for a patient in hypovolemic shock is: A. A drop in systolic blood pressure (SBP) 10 mm Hg for 1 minute when sitting up B. A change in mental status C. SaO2 of 88% D. Hemoglobin and hematocrit (H&H) 9 g/dL and 27% D. Hemoglobin and hematocrit (H & H) 9 g/dL and 27%. Hypovolemic shock occurs due to excessive blood loss, either through hemorrhage or internal bleeding. As blood is lost, hemoglobin is also lost, thus the hemoglobin levels will fall. The normal hemoglobin levels in an adult ranges from 12 - 17.5 g/DL while the normal hematocrit level ranges from 36% - 54%. In hypovolemic shock, the hemoglobin can fall to 9g/dL and the hematocrit can fall to 27%. The blood pressure is likely to fall more than 10mmgHg. The little blood left will be preferably channelled to the brain and the heart thus mental status will not be affected until much later. Question 7 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 B. Sepsis Patients with more chronic traumatic diaphragmatic hernias are most likely to present with sepsis. Chronic traumatic diaphragmatic hernias can cause bloodstream infections. Additionally, chronic traumatic diaphragmatic can trigger ventilator-associated pneumonia (VAT). Ventilator-Associated pneumonia can trigger the body to release chemicals into the bloodstream to fight the infections. As a consequence, the body's response to the bloodstream infections and ventilator-associated pneumonia can be out of balance. When the body's response to the chemicals is out of balance, the condition that occurs is sepsis References Question 8 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 C. Distributive This clinical picture is most consistent with distributive shock state. The vital signs and hemodynamic parameters make distributive shock as the likely shock state. The cardiac features of distributive shock include; a respiratory rate that is greater than 20 breaths per minute, increased pulse pressure, heart rate greater than 90 beats per minute, systolic blood pressure less than 90mmHg , and vascular resistance. The patient has a respiratory rate of 22 breaths per minute, and BP of 88/54mmHg Pulse. For this reason, this clinical picture is consistent with distributive shock state References Question 9 When counseling patients to prevent postoperative pulmonary complications, the AGACNP knows that with respect to smoking cessation, the American College of Surgeons and National Surgical Quality Improvement Program guidelines are clear that patients who stop smoking _____ weeks before surgery have no increased risk of smoking related pulmonary complications. A. 2 B. 4 C. 6 D. 8 Question 10 Mitch C. is a 39-year-old male who is brought to the ED by paramedics. According to the report of a neighbor, Mitch was distraught over a breakup with his fiancée and attempted to commit suicide by mixing some chemicals from under his kitchen sink and drinking them; afterward he changed his mind and knocked on his neighbor’s door asking for help. Mitch is awake but stuporous, and the neighbor has no idea what he drank. Visual inspection of his mouth and oropharynx reveals some edema and erythema. He is coughing and has large amounts of pooling saliva. Mitch is not capable of answering questions but he appears in pain. Endoscopy reveals full thickness mucosal injury with mucosal sloughing, ulceration, and exudate. The AGACNP knows that the appropriate course of treatment must include: A. At least 6 hours of observation in the emergency department B. Periodic esophagram C. Aggressive fluid resuscitation D. Esophagogastrectomy A. At least 6 hours of observation in the emergency department Patients who present at the emergency department due to poisoning, should be kept under observation for a minimum of 6 hours. Their stay in the emergency department could be as long as 72 hours. Esophagram is contraindicated in patients with ulcerations such as seen in Mitch C. Thus, period esophageal should not be performed on Mitch C. Fluid resuscitation should not be done for her since it can worsen her edema. Also, esophagoastrectomy is too radical and unnecessary for Mitch C since her poisoning burns are only as deep as the epithelial mucosa and can heal with medication. The correct option is thus: A. At least 6 hours of observation in the emergency department Question 11 Jared V. is a 35-year-old male who presents for evaluation of a dry cough. He reports feeling well overall but notices that he gets out of breath more easily than he used to when playing soccer. A review of systems yields results that are essentially benign, although the patient does admit to an unusual rash on his legs. Physical examination reveals scattered erythematous nodules on both shins. There is no drainage, discomfort, or itch. Additionally, diffuse, mildly enlarged lymph nodes are appreciated bilaterally. Results of a comprehensive metabolic panel and complete blood count are within normal limits. Twelve-lead ECG reveals sinus bradycardia at 58 bpm. Chest radiography reveals bilateral hilar and mediastinal lymphadenopathy. The AGACNP suspects: A. Bronchiectasis B. Pulmonary fibrosis C. Sarcoidosis D. Lung carcinoma C. Sarcoidosis Sarcoidosis is an inflammatory condition that affects various parts of the body especially the lungs and lymph nodes. It is the most common cause of bilateral hilar and mediastinal lymphadenopathy. The symptoms of sarcoidosis include: dry cough, shortness of breath, chest pain and a rash known as erythema nodosum. Signs elicited on physical examination can include: bradycardia, lymph node enlargement and erythematous nodules. From the medical history and physical examination findings consistent with the above signs and symptoms, the AGACNP suspects that Jared has Sarcoidosis. Question 12 Mrs. Miller is a 44-year-old female who is on postoperative day 1 following a total abdominal hysterectomy. Her urine output overnight was approximately 200 mL. The appropriate response for the AGACNP would be to order: A. A urinalysis and culture B. 1 liter of NSS over 8 hours C. Encourage increased mobility D. Liberalize salt in the diet A. Urinalysis and culture The patient's urinary output is really low and this needs urinalysis and culture to diagnose the condition that is causing a low urinary output. Urinalysis and culture will help in the detection of bacteria and urinary tract infections. The urinalysis and culture will help in the examination of the kidney functioning. Urinalysis and culture need to be done before the other steps can be recommended References Question 13 All of the following are risk factors for spontaneous pneumothorax except: A. Connective tissue disease. B. Scuba diving C. Chronic obstructive pulmonary disease (COPD) D. Central line insertion B. Scuba diving Scuba diving is not one of the risk factors for spontaneous pneumothorax because the divers carry a self-contained underwater breathing apparatus. The self-contained underwater breathing apparatus (scuba) is independent from the surface supply. The divers are able to breathe without having to hold their breath. Non-scuba diving is one of the risk factors to spontaneous pneumothorax because the divers are forced to hold breath while they are underwater. As a consequence, too much pressure builds up in the lungs which can cause the tearing of the lung tissues, leakage of air into the intra-pleural space, and interruption of the negative pressure in the pleural layers. This way, the lungs may collapse. Spontaneous pneumothorax can be a complication of the central line insertion. Other conditions such as connective tissue disease, and chronic obstructive pulmonary disease increases the likelihood of spontaneous pneumothorax References Question 14 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. Decrease p.o. intake and produce nutritional risk C. Contribute to risk of delirium and prolonged length of stay Sleep disruption and anxiety have been cited as essential etiological factor that is linked with the development of delirium. Postoperative delirium may result in increased mortality, worse functional status, higher healthcare costs and longer hospital stays. Sleep disturbance and anxiety are the increased the likelihood of the development of delirium. For this reason, there is a greater need to avoid the sleep disruption and anxiety before the surgery to prevent risk of delirium and prolonged length of stay Reference Leung, JM., et al. (2015). Preoperative sleep disruption and postoperative delirium. Retrieved from Question 15 In a patient with thyroid nodules, which of the following is the diagnostic study of choice to rule out thyroid cancer? A.Radioiodine scanning B. Percutaneous needle biopsy C. CT scan D.Ultrasound Question 16 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 C. Pneumatic dilation Pneumatic dilation is the treatment of choice for achalasia. The initial therapy for the treatment of achalasia should be pneumatic dilation. Pneumatic dilation (PD) is the first line of treatment for achalasia. Pneumatic dilation (PD) will offer a long term recovery from achalasia References Question 17 Mr. Liu is a 52-year-old male who has a history of thyroidectomy. He presents complaining of numbness and tingling in his legs and feet and generalized fatigue. Physical examination reveals a positive Chvostek’s sign. Which of the following laboratory studies should be ordered first? A. Renal function tests B. Parathyroid hormone C. Calcium D. Magnesium D. Magnesium Low magnesium levels in the body can cause numbness, muscle weakness, muscle cramps, convulsions, abnormal eye movements, and generalized fatigue. This condition is known as hypomagnesemia. Three conditions causes a positive Chvostek sign; hypocalcemia, hypomagnesemia , and metabolic alkalosis. From the symptoms presented magnesium level test should be ordered first. Mr. Liu is more likely to be suffering from hypomagnesemia References Question 18 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 19 The lower esophageal sphincter is characterized by periods of intermittent relaxation called transient lower esophageal sphincter relaxations. These relaxations are independent of the relaxation triggered by swallowing and are the most common cause of: A. Physiologic reflux B. Symptomatic esophagitis C. Barrett’s metaplasia D. Esophageal carcinoma C. Barret's metaplasia Transient lower esophageal sphincter relaxations cause a pathological reflux (not physiological reflux) known as GERD (Gastroesophageal reflux disease). The acidic contents of the stomach are able to pass through the loose lower esophageal sphincter and cause ulcerations on the epithelial mucosa. If the condition becomes chronic, then the acid transforms the cells of the esophageal epithelium from squamous cells to columnar cells. This process of cell transformation is known as Barret's metaplasia. Question 20 While reviewing morning labs on a postoperative patient, the AGACNP notes that the patient’s basic metabolic panel is as follows: Na+ 132 mEq/L K+ 4.6 mEq/L Cl- 87 mEq/L CO2 25 mEq/L A normal saline infusion is ordered in an attempt to avoid: A. Hyperkalemia B. Hypernatremia C. Metabolic alkalosis D. Metabolic acidosis C. Metabolic alkalosis Since the normal Cl- levels range between 96 - 106 mEq/L, the patient's Cl- level of 87 mEq/L is below the normal range. Cl- ions are acidic and thus they contribute to the body's acidity. Since the Cl- levels are below normal, then the patient is at risk of alkalosis. Normal saline can be used to correct Cl- levels since it contains Cl- ions. Therefore, the normal saline given to the patient helps to avoid Metabolic alkalosis. Question 21 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 22 Which of the following treatment modalities has no role in the treatment of shock? A. Lactated Ringer’s B. Fresh frozen plasma (FFP) C. Vasopressors D. Colloid solutions B. Fresh frozen plasma (FFP) Fresh frozen plasma (FFP) is not one of the treatment modalities that play a role in the treatment of shock. Lactated Ringer's solution is used in the treatment of hemorrhagic shock. Lactated Ringer's solution controls the source of bleeding and replaces the fluid that result from hemorrhagic shock. Colloid solutions are used in the treatment of hypovolemic shock. Colloid solutions have been shown to be more effective than crystalloids. Vasopressors play a role in the treatment of hemorrhagic and hypovolemic shock. For this reason, the fresh frozen plasma (FFP) is the odd one out from the choices References Question 23 The development of coronary artery disease (CAD) and, ultimately, plaque formation is a multifactorial process that includes endothelial injury from hypertension, cigarette smoking, and dyslipidemia. These events lead to endothelial cell dysfunction, which is theorized to result in: A. Decreased nitric oxide production B. Smooth muscle cell atrophy C. Collagen degradation. D. Enlarged arterial lumen Question 24 Mr. Comstock is a 71-year-old male who presents with a general sense of feeling weak and unwell; he thinks he has the flu even though he received a flu vaccination this year. He describes a vague collection of symptoms, including weakness, nausea, dizziness, and “getting out of breath” very easily. He says he can barely climb the steps anymore without stopping to rest. Of the possible differential diagnoses, coronary artery disease (CAD) is high among the probabilities because of his age and gender. His physical examination is unremarkable except that he appears weak. His vital signs are as follows: temperature 98.0°F, pulse 100 bpm, respiratory rate 16 b.p.m., and BP 178/100 mm Hg. A chest radiograph is within normal limits with no acute pulmonary infection. A 12-lead ECG reveals inverted T waves in leads V1 to V5. The AGACNP is suspicious that most of his symptoms are: A. Psychosomatic B. Early congestive heart failure (CHF) C. Anginal equivalents D. Normal age-related changes B. Early congestive heart failure (CHF) Early congestive heart failure (CHF) occurs when the heart cannot pump enough blood to meet the body's needs. It occurs when the heart pumping efficiency is impaired. The early symptoms of heart failure include; diminished exercise capacity, swelling, and shortness of breath. In class II heart failure, a person may be comfortable at rest but the physical activities such as walking may case shortness of breath fatigue and palpitations. From the symptoms presented, Mr. Comstock might be class II congestive heart failure Reference Question 25 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 A. Acute mitral valve regurgitation Acute mitral valve regurgitation is associated with fatigue, reduced ability to exercise, shortness of breath when lying flat, palpitations, chest pains and the swelling of the abdomen and veins in the neck. Acute mitral valve regurgitation physical examination includes a grade V/VI systolic murmur that is loudest at the point of maximal impulse with radiation to the midaxillary line. The abnormal heart rhythms make the heart unable to pump effectively. This cases, the murmur at the midaxillary line References Question 26 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 B. Long-term results suggest that the grafts do not stay open as long as those in traditional bypass grafting The traditional methods of performing bypass surgery are not only expensive but they do result in more complications and morbidities. The off pump coronary artery bypass has gained popularity than the traditional methods because it causes less morbidity, inflammation and is more cost effective. Off-pump bypass surgery involves the stabilization of blocked coronary artery by grafting the blood vessel on the pumping heart. As a consequence, the grafts would not stay open as long as those in traditional bypass grafting References Question 27 Mrs. McCallum is a 48-year-old female who presents for evaluation of a vague set of gastrointestinal symptoms. She feels generally well and has always been healthy, but lately she has had a lot of heartburn and a sense of reflux in her throat. Most recently she has had a recurring sense of food getting stuck in her throat. The AGACNP knows that which diagnostic study should be performed first? A. Barium swallow B. Upper endoscopy C. Esophageal manometry D. Ambulatory pH monitoring Question 28 Mr. Key is a 53-year-old male patient who developed empyema following a serious bout of bacterial pneumonia. He presented as septic and was started immediately on intravenous antibiotics and drainage of the sinus cavity. Forty-eight hours later, he is much improved clinically and drainage has receded. The next step in his care would be: A. A CT scan B. Eloesser’s procedure C. Decortication D. Reexpansion C. Decortication Decortication is a procedure that is recommended after the drainage of the sinus cavity and the patient responds positively. Re-expansion is a surgical procedure that gets rid of the restrictive layer of fibrous tissue overlying the diaphragm, chest wall and the lungs. The 53-year-old male patient does not have a chronic empyema and this makes decortication the appropriate procedure. Eloesser's procedure would only be performed if the patient presented with a chronic empyema References Question 29 Mrs. Bowers is a 41-year-old patient who requires surgical management of osteomyelitis. She has a long history of methamphetamine use and has a BMI of 17.9 kg/m2 . She clearly is nutritionally depleted and volume contracted, but she has no clear chronic medical history except for unmedicated hypertension, which may be due to her chronic stimulant use. She denies alcohol use but admits to a 1½ pack a day cigarette habit. A primary postoperative concern for Mrs. Bowers is: A. Excess bleeding B. Thromboemboli development C. Poor wound healing D. Renal failure Question 30 The congenital diaphragmatic hernia that occurs more often in women and does not usually produce symptoms until midlife is known as: A. Zenker’s hernia B. Bochdalek’s hernia C. Morgagni’s hernia D. Atraumatic hernia D. Atraumatic hernia Atraumatic hernia is a kind of congenital diaphragmatic hernia that occurs more often in women. Atraumatic hernia does not usually produce symptoms until midlife. Atraumatic hernia affects women after midlife. Atraumatic hernia is a rare condition that its effect are secondary in that they do not show up until midlife References Ng P C, Chua AN, Swanson MS, Koutlas T C, Chitwood W R, Elbeery J R. Anterior thoracotomy wound complications in minimally invasive direct coronary artery bypass. Ann. Thorac. Surg. 2000 May;69 (5):1338-40. Question 31 B. is a 67-year-old male