What is the maximum half-life elimination of warfarin (Coumadin)?
Rational: The half-life elimination of warfarin (Coumadin) is 20-60 hours. The onset of anticoagulant action for oral warfarin (Coumadin) is 24-72 hours. Warfarin acts by inhibiting the synthesis of vitamin K-dependent clotting factors, including Factors II, VII, IX, and X, and the anticoagulant proteins C and S.
A birth defect characterized by a hole in the septum that separates the two upper chambers of the heart is:
ventricular septal defect.
patent ductus arteriosus.
atrial septal defect.
tetralogy of Fallot.
Rational: An atrial septal defect is a birth defect in which a hole exists in the septum dividing the upper chambers (atria) of the heart. The hole increases the amount of blood that flows through the lungs and over time, it may cause damage to the blood vessels in the lungs. Damage to the blood vessels in the lungs may cause problems in adulthood, such as high blood pressure in the lungs and heart failure. Other problems may include abnormal heartbeat, and increased risk of stroke.
When examining a patient with atopic dermatitis, there is a thickening and roughening of the skin with increased visibility of the normal skin furrows. This condition is termed:
burrow of scabies.
Rational: Lichenification is defined as the thickening and roughening of the skin with increased visibility of the normal skin furrows (numerous grooves of variable depth on the surface of the epidermis). Atrophy is thinning of the skin with loss of normal skin furrows. Excoriation of the skin is an abrasion or scratch mark. The burrow of a scabies lesion includes small papules, pustules, lichenified areas and excoriations.
A female patient has the following characteristics. Which one represents the greatest risk factor for development of type 2 diabetes?
LDL < 100 mg/dL
Lack of regular healthcare
Rational: A BMI of 25 or higher imparts an increased risk of type 2 diabetes. Mediterranean descent does not impart a specific risk factor for type 2 diabetes, but African-American, Asian-American, and Hispanic ethnicities have an increased risk.
When auscultating the enlarged thyroid with a stethoscope, a bruit is suggestive of:
a carotid aneurysm.
a normal finding.
a thyroid malignancy.
Rational: A systolic or continuous bruit auscultated with a stethoscope over an enlarged thyroid may be heard in hyperthyroidism. This is not a normal finding. A bruit is not usually associated with a thyroid malignancy.
A patient is started on a sulfonylurea (i.e., glyburide). The nurse practitioner informs the patient that sulfonylureas are likely to:
cause weight loss.
reduce microvascular events.
delay gastric emptying.
reduce the risk of hypoglycemic events.
Rational: The advantages of sulfonylureas such as glyburide (DiaBeta) are that they are low cost, have a long use history, and cause a reduction in micro/macrovascular events. Disadvantages are they produce hypoglycemia and cause weight gain. Glucagon-like peptide (GLP-1) incretin mimetics cause weight loss and delay gastric emptying.
Ophthalmoscopic examination of the fundus reveals small, rounded, slightly irregular red spots embedded in the retina. These findings are consistent with:
superficial retinal hemorrhages.
deep retinal hemorrhages.
Rational: Deep retinal hemorrhages appear as small, rounded, slightly irregular red spots and are sometimes called dot or blot hemorrhages. They occur in a deeper layer of the retina than flame-shaped hemorrhages. Diabetes is a common cause. Superficial retinal hemorrhages appear as small, linear, flame-shaped, red streaks in the fundi and are seen in hypertension, papilledema, and occlusion of the retinal vein. Preretinal hemorrhages lie anteriorly between the retina and the vitreous and are typically larger than retinal hemorrhages. These hemorrhages obscure any underlying retinal vessel. Microaneurysms present as tiny, round, red spots commonly seen in and around the macular area. These are classic in diabetic retinopathy.
The first step in the pathogenesis of otitis externa is:
edema and pruritus, resulting in obstruction.
otalgia, resulting in hearing loss.
breakdown of the cerumen barrier.
increased pH in the ear.
Rational: Breakdown of the skin-cerumen barrier is the first step in the pathogenesis of otitis externa. Inflammation and edema of the skin then leads to pruritus and obstruction. The pruritus prompts scratching that may create further injury. This sequence of events alters the quality and amount of cerumen, impairs epithelial migration, and increases the pH of the ear canal. The resulting dark, warm, alkaline, moist ear canal becomes an ideal breeding ground for numerous organisms.
An older adult has suspected vitamin B12 deficiency. Which of the following lab indices is more indicative of a vitamin B12 deficiency?
Rational: A vitamin B12 deficiency can produce an anemia called pernicious anemia. This is most commonly found in older adults and is characterized by macrocytosis. In other words, the red cells are larger than expected. Microcytosis may be seen in iron deficiency anemia or thalassemia. Leukocytosis refers to large numbers of white cells in the blood stream. Thrombocytosis refers to an increased number of platelets in the blood stream.
The type of hernia in which the hernial sac protrudes directly through the abdominal wall in the region of Hesselbach triangle is called a(n):
Rational: The type of hernia in which the hernial sac protrudes directly through the abdominal wall in the region of Hesselbach triangle is called an inguinal hernia. The inguinal triangle represents an area of potential weakness in the abdominal wall through which herniation can occur. Inguinal hernias may be direct, entering the inguinal canal, or indirect, in which the bowel enters the inguinal canal via the deep inguinal ring.
Folic acid deficiency is an example of which type of anemia?
Rational: Macrocytic anemia is characterized by larger than normal red blood cells. Vitamin B12 and folate deficiencies are examples of macrocytic anemias. Normocytic anemia is caused by acute blood loss, chronic disease, or failure to produce adequate red blood cells. Chronic renal failure (decreased production of erythropoietin) or liver failure causes normocytic anemia. Microcytic anemia usually occurs in iron deficiency anemia. Hemolytic anemia can be autoimmune, hereditary or mechanical. It can result (because of cell fragmentation) in a microcytic anemia, a normochromic anemia, or (because of premature release of immature red blood cells from the bone marrow), a macrocytic anemia.
Prostate gland enlargement that narrows the urethral lumen and leads to increased prostatic smooth muscle tone is:
benign prostatic hyperplasia.
Rational: Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland that narrows the urethral lumen and leads to increased prostatic smooth muscle tone. It develops primarily in the periurethral or transitional zone of the prostate. The pathogenesis of BPH is incompletely understood; older age and the presence of functioning Leydig cells of the testes are essential for its development. In men younger than 40 years who have low testosterone levels (and who are not treated with androgen), BPH is rare.
A 25-year-old pregnant woman has asymptomatic bacteriuria. The best treatment plan for this patient is to:
have her return if she becomes symptomatic.
administer gentamicin intramuscularly for one dose.
initiate cephalexin (Keflex) for 7 days.
prescribe trimethoprim/sulfamethoxazole (Bactrim) for 3 days.
Rational: Without treatment, 30% to 40% of pregnant women with asymptomatic bacteriuria will develop a symptomatic urinary tract infection (UTI), including pyelonephritis. They are also more likely to deliver premature or low-birth-weight infants. The current recommendation is to administer a 3- to 7-day course of antimicrobial therapy to pregnant women with asymptomatic bacteriuria. The safest choices of treatment are amoxicillin (Moxatag), cefuroxime (Zinacef), cephalexin (Keflex) and nitrofurantoin (Macrobid). Macrobid should be avoided in the first trimester if possible. Ciprofloxacin (Cipro), levofloxacin (Levaquin) and trimethoprim/sulfamethoxazole (Bactrim) should only be prescribed if the benefits outweigh the risks, since safety has not been established in pregnancy. Aminoglycosides (i.e., gentamicin) should be avoided during pregnancy.
A patient you are caring for in your clinic has Medicare Part B. What does this mean?
The federal government will pay for his visit to your clinic today.
His medicare benefit covers outpatient services.
He will have a copay for his visit today.
His prescriptions will be partly paid for today.
Rational: Part B pays the examiner (NP, PA, MD, etc.). Part B of Medicare pays for outpatient care, ambulatory surgery services, X-rays, durable medical equipment, laboratory, and home health. Part B is an option that Medicare recipients can pay for with a monthly option. This charge is based on income. Since there is an initial copay, the federal government's insurance plan may NOT pay for his visit to your clinic today.
An Infection of the tracheobronchial tree that causes reversible bronchial inflammation is:
upper respiratory disease.
Rational: Bronchitis develops when mucous membranes in the tracheobronchial tree become hyperemic and edematous. This increases bronchial secretions and causes destruction of epithelium-impaired mucociliary activity. In most cases, the infection has a nonbacterial cause. Viral illness is frequently associated with this lower respiratory tract disease.
A female patient has been diagnosed with chlamydia. How should this be managed?
Treat with azithromycin
Treat with ceftriaxone by injection
Treat with doxycycline
Treat for gonorrhea also
Rational: Chlamydia is commonly treated with a single dose of azithromycin (1 gram). This patient should be screened for other STDs now, including hepatitis B, C and HIV. According to the 2015 STD guidelines, this patient should not be treated for gonorrhea unless this is diagnosed too.