NR511 Nursing Diagnosis Midterm Exam With Answers (401 Solved Questions)
NR511 Nursing Diagnosis Midterm Exam With Answers helps you track your progress with real past exam questions.
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1
Q bank questions
Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be considered?
(Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than 5 days’
duration. The incubation period for pertussis is about 7-10 days. Patients present with URI symptoms for
1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of
symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious
and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose
because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations).
Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI
symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratory
symptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchial
pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration,
and atelectasis. These are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase risk of
sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with an inhaled
steroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is an
increased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma.
The other choices can be used to treat asthma. Choices vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years
should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled
steroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably has
emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk
factor. Screening for osteoporosis should be considered when managing patients with multiple risk
factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to
your clinic today. What recommendation should be made about the pneumococcal immunization? (He
should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed
since his last one. The CDC does not recommend immunizing this patient every 5 years. Two
immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered
today. PPSV23 should be administered at least 1 year later.
Q bank questions
Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be considered?
(Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than 5 days’
duration. The incubation period for pertussis is about 7-10 days. Patients present with URI symptoms for
1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of
symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious
and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose
because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations).
Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI
symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratory
symptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchial
pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration,
and atelectasis. These are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase risk of
sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with an inhaled
steroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is an
increased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma.
The other choices can be used to treat asthma. Choices vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years
should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled
steroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably has
emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk
factor. Screening for osteoporosis should be considered when managing patients with multiple risk
factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to
your clinic today. What recommendation should be made about the pneumococcal immunization? (He
should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed
since his last one. The CDC does not recommend immunizing this patient every 5 years. Two
immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered
today. PPSV23 should be administered at least 1 year later.
1
Q bank questions
Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be considered?
(Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than 5 days’
duration. The incubation period for pertussis is about 7-10 days. Patients present with URI symptoms for
1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of
symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious
and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose
because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations).
Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI
symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratory
symptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchial
pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration,
and atelectasis. These are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase risk of
sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with an inhaled
steroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is an
increased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma.
The other choices can be used to treat asthma. Choices vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years
should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled
steroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably has
emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk
factor. Screening for osteoporosis should be considered when managing patients with multiple risk
factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to
your clinic today. What recommendation should be made about the pneumococcal immunization? (He
should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed
since his last one. The CDC does not recommend immunizing this patient every 5 years. Two
immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered
today. PPSV23 should be administered at least 1 year later.
Q bank questions
Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be considered?
(Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than 5 days’
duration. The incubation period for pertussis is about 7-10 days. Patients present with URI symptoms for
1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of
symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious
and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose
because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations).
Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI
symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratory
symptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchial
pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration,
and atelectasis. These are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase risk of
sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with an inhaled
steroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is an
increased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma.
The other choices can be used to treat asthma. Choices vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years
should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled
steroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably has
emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk
factor. Screening for osteoporosis should be considered when managing patients with multiple risk
factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to
your clinic today. What recommendation should be made about the pneumococcal immunization? (He
should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed
since his last one. The CDC does not recommend immunizing this patient every 5 years. Two
immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered
today. PPSV23 should be administered at least 1 year later.
2
Which of the following medications should be used cautiously in a patient who has asthma? (Timolol
ophthalmic drops)
Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in patients who
have asthma. Even though timolol is being administered in the eye, it is absorbed through mucous
membranes and can exert systemic effects. Beta blockers should be avoided in patients with asthma and
used cautiously in patients with COPD. The other medications listed have no specific contraindications
for patients with asthma.
The most common symptom associated with acute bronchitis is: (Cough)
Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the most
common symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% of
patients with acute bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial
cells, not bacterial infection. Concurrent upper respiratory symptoms are typical of acute bronchitis.
Pharyngitis is common.
Mild persistent asthma is characterized by: (symptoms occurring more than twice weekly)
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but not daily; or
3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily, and a
bronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should be
stepped up. Generally, a long-acting bronchodilator is added to the steroid when therapy is stepped up.
The chest circumference of a 12 month-old is: (equal to head circumference)
The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern
about the circumference of either the head or the chest. An exception to this observation can occur in
premature infants where the head grows very rapidly. Normally, the head exceeds the chest
circumference by 1-2 cm from birth until 6 months. Between 6 and 24 months the head and chest
circumference should be about equal and by 2 years of age the chest should be larger than the head. The
chest circumference is measured at the nipple line.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely diagnosis?
(Pneumonia)
The finding of infiltrates on chest x-ray, in conjunction with clinical findings of fever and cough, should
direct the examiner to consider pneumonia as the diagnosis. Other common clinical findings with
pneumonia include chest pain, dyspnea, and sputum production. Though not common, some patients
with pneumonia exhibit gastrointestinal symptoms like nausea, vomiting, and diarrhea.
An uncommon symptom associated with acute bronchitis is: (temperature > 101°F)
Fever is an unusual symptom associated with acute bronchitis. Cough is the most common symptom
associated with acute bronchitis. Purulent sputum is identified in more than 50% of patients with acute
bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial cells, not bacterial
infection. Concurrent upper respiratory symptoms are typical of acute bronchitis. Pharyngitis is common
within the first 3 days of the illness.
Patients who have cough-variant asthma: (all exhibit cough)
Which of the following medications should be used cautiously in a patient who has asthma? (Timolol
ophthalmic drops)
Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in patients who
have asthma. Even though timolol is being administered in the eye, it is absorbed through mucous
membranes and can exert systemic effects. Beta blockers should be avoided in patients with asthma and
used cautiously in patients with COPD. The other medications listed have no specific contraindications
for patients with asthma.
The most common symptom associated with acute bronchitis is: (Cough)
Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the most
common symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% of
patients with acute bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial
cells, not bacterial infection. Concurrent upper respiratory symptoms are typical of acute bronchitis.
Pharyngitis is common.
Mild persistent asthma is characterized by: (symptoms occurring more than twice weekly)
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but not daily; or
3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily, and a
bronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should be
stepped up. Generally, a long-acting bronchodilator is added to the steroid when therapy is stepped up.
The chest circumference of a 12 month-old is: (equal to head circumference)
The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern
about the circumference of either the head or the chest. An exception to this observation can occur in
premature infants where the head grows very rapidly. Normally, the head exceeds the chest
circumference by 1-2 cm from birth until 6 months. Between 6 and 24 months the head and chest
circumference should be about equal and by 2 years of age the chest should be larger than the head. The
chest circumference is measured at the nipple line.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely diagnosis?
(Pneumonia)
The finding of infiltrates on chest x-ray, in conjunction with clinical findings of fever and cough, should
direct the examiner to consider pneumonia as the diagnosis. Other common clinical findings with
pneumonia include chest pain, dyspnea, and sputum production. Though not common, some patients
with pneumonia exhibit gastrointestinal symptoms like nausea, vomiting, and diarrhea.
An uncommon symptom associated with acute bronchitis is: (temperature > 101°F)
Fever is an unusual symptom associated with acute bronchitis. Cough is the most common symptom
associated with acute bronchitis. Purulent sputum is identified in more than 50% of patients with acute
bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial cells, not bacterial
infection. Concurrent upper respiratory symptoms are typical of acute bronchitis. Pharyngitis is common
within the first 3 days of the illness.
Patients who have cough-variant asthma: (all exhibit cough)
3
One of the most common causes of cough in adults is asthma. Cough due to asthma is often
accompanied by episodic wheezing or dyspnea, though some patients who have asthma only cough. This
is termed “cough-variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of
the airways is a typical finding.
The most common cause of atypical pneumonia in adults is: (Mycoplasma pneumonia)
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M. pneumoniae
is so named because of its atypical appearance on chest X-ray. This organism is responsible for “walking
pneumonia” that is prevalent in a young adult population. This accounts for about 15% of pneumonia
and is transmitted via respiratory droplet.
Which patient might be expected to have the worst FEV1? (A 65-year-old with emphysema)
FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is forcefully
exhaled in the first second of exhalation after a deep breath. Patients with emphysema are not able to
do this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV 1 is used to
assess airway obstruction. An asthma patient in the green zone would be expected to have a normal
(compared to himself) FEV1. An FEV1 measurement or pulmonary function tests would not be
performed on a patient with pneumonia or bronchiectasis because he would have diminished
respiratory capacity related to his infection.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has
wheezing and diminished breath sounds in the upper right lobe. His cough is nonproductive, and he
denies nasal symptoms. Which symptom is not likely related to his asthma? (Fever)
Wheezing is typical of asthma, but one must consider pneumonia in any patient who presents with
diminished breath sounds in only one lobe. Fever is not typical of asthma or an exacerbation.
Ipratropium is very widely used in the treatment of COPD. Which of the following statements about
ipratropium is correct? (It decreases parasympathetic tone and produces bronchodilation)
Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. It
produces its helpful effects by reducing cholinergic tone in the lungs. It may be used with a beta agonist
if shortness of breath is present. However, beta agonists increase side effects like tachycardia and tremor
and do not improve efficacy.
One of the most common causes of cough in adults is asthma. Cough due to asthma is often
accompanied by episodic wheezing or dyspnea, though some patients who have asthma only cough. This
is termed “cough-variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of
the airways is a typical finding.
The most common cause of atypical pneumonia in adults is: (Mycoplasma pneumonia)
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M. pneumoniae
is so named because of its atypical appearance on chest X-ray. This organism is responsible for “walking
pneumonia” that is prevalent in a young adult population. This accounts for about 15% of pneumonia
and is transmitted via respiratory droplet.
Which patient might be expected to have the worst FEV1? (A 65-year-old with emphysema)
FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is forcefully
exhaled in the first second of exhalation after a deep breath. Patients with emphysema are not able to
do this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV 1 is used to
assess airway obstruction. An asthma patient in the green zone would be expected to have a normal
(compared to himself) FEV1. An FEV1 measurement or pulmonary function tests would not be
performed on a patient with pneumonia or bronchiectasis because he would have diminished
respiratory capacity related to his infection.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has
wheezing and diminished breath sounds in the upper right lobe. His cough is nonproductive, and he
denies nasal symptoms. Which symptom is not likely related to his asthma? (Fever)
Wheezing is typical of asthma, but one must consider pneumonia in any patient who presents with
diminished breath sounds in only one lobe. Fever is not typical of asthma or an exacerbation.
Ipratropium is very widely used in the treatment of COPD. Which of the following statements about
ipratropium is correct? (It decreases parasympathetic tone and produces bronchodilation)
Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. It
produces its helpful effects by reducing cholinergic tone in the lungs. It may be used with a beta agonist
if shortness of breath is present. However, beta agonists increase side effects like tachycardia and tremor
and do not improve efficacy.
4
An 80-year-old has Stage 3 COPD. He is most likely to have concomitant: (anxiety or depression)
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It should be
treated because it affects the overall management of COPD. COPD is characterized by airflow limitation
and dyspnea. This may contribute to feelings of chronic anxiety. Additionally, many chronic diseases are
associated with depression. This is the case with COPD.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after chest X-ray
and laboratory studies. He developed a sudden onset of fever with chills. He is in no distress. What is
the preferred treatment for him? (Amoxicillin)
In children who are older than 5 years of age, the most common bacterial pathogen is an atypical
pathogen. Because this child has asthma and uses an inhaled steroid daily, the most likely pathogen is
Streptococcus pneumoniae. An abrupt onset of fever and chills is suggestive of Streptococcal
pneumonia. Amoxicillin is usually chosen first for its efficacy, cost, and tolerability. The higher dose (80-
100 mg/kg/d) is chosen because of the prevalence of resistant Streptococcus pneumoniae. Azithromycin
would be chosen if an atypical pathogen was more likely. Doxycycline is not an appropriate choice
because it has poor Strep coverage and it is contraindicated in children younger than 8 years.
What disease is usually managed with a short-acting or long-acting inhaled anticholinergic
medication? (COPD)
First-line treatment for patients with COPD who have intermittent symptoms of shortness of breath is an
anticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonist
may be used. Anticholinergic medications are not used as a lone agents to manage symptoms of asthma;
inhaled steroids usually are. Bronchitis is a viral infection that is self-limited and usually does not require
an inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanently
enlarged. Symptoms include chronic production of purulent mucous.
A patient with pneumonia reports that he has rust-colored sputum. What pathogen should the nurse
practitioner suspect? (Streptococcus pneumonia)
An 80-year-old has Stage 3 COPD. He is most likely to have concomitant: (anxiety or depression)
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It should be
treated because it affects the overall management of COPD. COPD is characterized by airflow limitation
and dyspnea. This may contribute to feelings of chronic anxiety. Additionally, many chronic diseases are
associated with depression. This is the case with COPD.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after chest X-ray
and laboratory studies. He developed a sudden onset of fever with chills. He is in no distress. What is
the preferred treatment for him? (Amoxicillin)
In children who are older than 5 years of age, the most common bacterial pathogen is an atypical
pathogen. Because this child has asthma and uses an inhaled steroid daily, the most likely pathogen is
Streptococcus pneumoniae. An abrupt onset of fever and chills is suggestive of Streptococcal
pneumonia. Amoxicillin is usually chosen first for its efficacy, cost, and tolerability. The higher dose (80-
100 mg/kg/d) is chosen because of the prevalence of resistant Streptococcus pneumoniae. Azithromycin
would be chosen if an atypical pathogen was more likely. Doxycycline is not an appropriate choice
because it has poor Strep coverage and it is contraindicated in children younger than 8 years.
What disease is usually managed with a short-acting or long-acting inhaled anticholinergic
medication? (COPD)
First-line treatment for patients with COPD who have intermittent symptoms of shortness of breath is an
anticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonist
may be used. Anticholinergic medications are not used as a lone agents to manage symptoms of asthma;
inhaled steroids usually are. Bronchitis is a viral infection that is self-limited and usually does not require
an inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanently
enlarged. Symptoms include chronic production of purulent mucous.
A patient with pneumonia reports that he has rust-colored sputum. What pathogen should the nurse
practitioner suspect? (Streptococcus pneumonia)
5
Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, but
certain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, also
known as pneumococcal pneumonia, is associated with rust-colored sputum. Scant or watery sputum is
associated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia. Thick, discolored
sputum may be associated with bacterial pneumonia.
A 44-year-old nonsmoker is diagnosed with pneumonia. He is otherwise healthy and does not need
hospitalization at this time. Which antibiotic can be used for empirical treatment of pneumonia
according to the most recent Infectious Diseases Society of America/American Thoracic Society
guidelines? (Azithromycin)
The guidelines recommend macrolide use or doxycycline for initial treatment of uncomplicated
pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. The
initial choices can be any of these: azithromycin, clarithromycin, or doxycycline. These agents are chosen
because they cover atypical pathogens, the most likely pathogen in this population. Fluoroquinolones
are commonly used first line in these patients; however, the guidelines strongly recommend using
fluoroquinolones for patients with comorbidities or patients who have recent antibiotic exposure.
The gold standard for diagnosing pneumonia on chest X-ray is the presence of: (Infiltrates)
The finding of infiltrates on chest X-ray, in conjunction with clinical findings of fever, chest pain, dyspnea,
and sputum production on clinical exam, should direct the examiner to consider pneumonia as the
diagnosis.
An 83-year-old healthy adult is diagnosed with pneumonia. He is febrile but in no distress. What is the
preferred treatment for him? (Levofloxacin)
At age extremes, the most common pathogen is Streptococcus pneumoniae. Because of the age of the
patient and the consequences of potential treatment failure, a respiratory quinolone should be
considered. Quinolone antibiotics can produce QT prolongation and should be used cautiously in older
adults. Azithromycin or doxycycline would be chosen if an atypical pathogen was suspected. This is
unlikely in this patient because of his age.
The pneumococcal immunization in infants has: (shifted the pathogenesis to fewer cases of S.
pneumonia)
The heptavalent pneumococcal conjugate vaccine (PCV13), Prevnar, protects children from 13 types of
pneumococcal bacteria. It has reduced the incidence of ear infections caused by S. pneumo and has
reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of
acute otitis media has shifted to more cases of H. influenzae, but this organism is less likely to become
resistant, as Strep pneumo has.
A 78-year-old adult who has a 50 pack year smoking habit asks the nurse practitioner about the
benefits of quitting “at my age.” What should the nurse practitioner reply? (This will decrease your risk
of all cause mortality 5 years after stopping)
Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Data
demonstrates that after 5 years of smoking cessation, there is a significant decrease in the risk of death
Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, but
certain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, also
known as pneumococcal pneumonia, is associated with rust-colored sputum. Scant or watery sputum is
associated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia. Thick, discolored
sputum may be associated with bacterial pneumonia.
A 44-year-old nonsmoker is diagnosed with pneumonia. He is otherwise healthy and does not need
hospitalization at this time. Which antibiotic can be used for empirical treatment of pneumonia
according to the most recent Infectious Diseases Society of America/American Thoracic Society
guidelines? (Azithromycin)
The guidelines recommend macrolide use or doxycycline for initial treatment of uncomplicated
pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. The
initial choices can be any of these: azithromycin, clarithromycin, or doxycycline. These agents are chosen
because they cover atypical pathogens, the most likely pathogen in this population. Fluoroquinolones
are commonly used first line in these patients; however, the guidelines strongly recommend using
fluoroquinolones for patients with comorbidities or patients who have recent antibiotic exposure.
The gold standard for diagnosing pneumonia on chest X-ray is the presence of: (Infiltrates)
The finding of infiltrates on chest X-ray, in conjunction with clinical findings of fever, chest pain, dyspnea,
and sputum production on clinical exam, should direct the examiner to consider pneumonia as the
diagnosis.
An 83-year-old healthy adult is diagnosed with pneumonia. He is febrile but in no distress. What is the
preferred treatment for him? (Levofloxacin)
At age extremes, the most common pathogen is Streptococcus pneumoniae. Because of the age of the
patient and the consequences of potential treatment failure, a respiratory quinolone should be
considered. Quinolone antibiotics can produce QT prolongation and should be used cautiously in older
adults. Azithromycin or doxycycline would be chosen if an atypical pathogen was suspected. This is
unlikely in this patient because of his age.
The pneumococcal immunization in infants has: (shifted the pathogenesis to fewer cases of S.
pneumonia)
The heptavalent pneumococcal conjugate vaccine (PCV13), Prevnar, protects children from 13 types of
pneumococcal bacteria. It has reduced the incidence of ear infections caused by S. pneumo and has
reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of
acute otitis media has shifted to more cases of H. influenzae, but this organism is less likely to become
resistant, as Strep pneumo has.
A 78-year-old adult who has a 50 pack year smoking habit asks the nurse practitioner about the
benefits of quitting “at my age.” What should the nurse practitioner reply? (This will decrease your risk
of all cause mortality 5 years after stopping)
Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Data
demonstrates that after 5 years of smoking cessation, there is a significant decrease in the risk of death
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6
from coronary disease, cancer, and COPD. The patient already has COPD if he has a 50 pack year habit.
All patients should be counseled to quit smoking regardless of age.
M. pneumoniae and C. pneumoniae are respiratory pathogens that: (cause atypical pneumonia)
These two organisms are common causes of pneumonia. They are called atypical pathogens because
they produce atypical pneumonia. They are transmitted via respiratory droplets from the nose and
throat of infected people. Prolonged close contact is probably needed for transmission to occur. Patients
are usually contagious for 10 days or so. Most commonly, these infections occur in younger patients, but
all ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics or
tetracyclines.
An 18-month-old child is diagnosed with bronchiolitis. His respiratory rate is 28 breaths per minute.
Which choice below is most appropriate for patient management? (Antipyretics)
Bronchiolitis is a viral infection and antibiotics would be inappropriate for management. Since fever
commonly accompanies bronchiolitis, antipyretics such as acetaminophen and ibuprofen are commonly
used. Bronchiolitis is characterized by wheezing. A normal respiratory rate for an 18-month-old is 20-30
breaths/minute. Bronchodilators, especially nebulized, and inhaled/oral steroids are commonly
employed to decrease respiratory effort. However, these interventions lack proven benefit, increase the
cost of care, and have many side effects.
How should a 20-year-old college age student who presents with cough, night sweats, and weight loss
be screened for TB? (A TB skin test)
Screening for TB in this patient should take place with a skin test known as the Mantoux. A chest X-ray is
typically performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. A
questionnaire is used for screening patients who have had a history of a positive TB skin test. If
symptoms are acknowledged on the questionnaire, a chest X-ray may be performed. The questionnaire is
used to prevent inappropriate exposure to radiation in patients in whom regular screening is required,
like healthcare providers.
An example of a short-acting beta agonist is: (levalbuterol)
An example of a short-acting beta agonist is albuterol or levalbuterol. These provide rapid dilation of the
bronchioles and can give immediate relief for shortness of breath; hence the term for this class of
medications: rescue medications. Salmeterol is a long-acting beta agonist. These should never be used
without an inhaled steroid to treat a patient with asthma. Mometasone and beclomethasone are
steroids commonly used to treat patients with asthma.
A patient with asthma uses one puff twice daily of fluticasone and has an albuterol inhaler for PRN
use. He requests a refill on his albuterol inhaler. His last prescription was filled 5 weeks ago. What
action by the NP is appropriate? (Increase the dose of the inhaled steroid, refill the albuterol)
The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5
weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. His
inhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he should
not be without a prescription for the
from coronary disease, cancer, and COPD. The patient already has COPD if he has a 50 pack year habit.
All patients should be counseled to quit smoking regardless of age.
M. pneumoniae and C. pneumoniae are respiratory pathogens that: (cause atypical pneumonia)
These two organisms are common causes of pneumonia. They are called atypical pathogens because
they produce atypical pneumonia. They are transmitted via respiratory droplets from the nose and
throat of infected people. Prolonged close contact is probably needed for transmission to occur. Patients
are usually contagious for 10 days or so. Most commonly, these infections occur in younger patients, but
all ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics or
tetracyclines.
An 18-month-old child is diagnosed with bronchiolitis. His respiratory rate is 28 breaths per minute.
Which choice below is most appropriate for patient management? (Antipyretics)
Bronchiolitis is a viral infection and antibiotics would be inappropriate for management. Since fever
commonly accompanies bronchiolitis, antipyretics such as acetaminophen and ibuprofen are commonly
used. Bronchiolitis is characterized by wheezing. A normal respiratory rate for an 18-month-old is 20-30
breaths/minute. Bronchodilators, especially nebulized, and inhaled/oral steroids are commonly
employed to decrease respiratory effort. However, these interventions lack proven benefit, increase the
cost of care, and have many side effects.
How should a 20-year-old college age student who presents with cough, night sweats, and weight loss
be screened for TB? (A TB skin test)
Screening for TB in this patient should take place with a skin test known as the Mantoux. A chest X-ray is
typically performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. A
questionnaire is used for screening patients who have had a history of a positive TB skin test. If
symptoms are acknowledged on the questionnaire, a chest X-ray may be performed. The questionnaire is
used to prevent inappropriate exposure to radiation in patients in whom regular screening is required,
like healthcare providers.
An example of a short-acting beta agonist is: (levalbuterol)
An example of a short-acting beta agonist is albuterol or levalbuterol. These provide rapid dilation of the
bronchioles and can give immediate relief for shortness of breath; hence the term for this class of
medications: rescue medications. Salmeterol is a long-acting beta agonist. These should never be used
without an inhaled steroid to treat a patient with asthma. Mometasone and beclomethasone are
steroids commonly used to treat patients with asthma.
A patient with asthma uses one puff twice daily of fluticasone and has an albuterol inhaler for PRN
use. He requests a refill on his albuterol inhaler. His last prescription was filled 5 weeks ago. What
action by the NP is appropriate? (Increase the dose of the inhaled steroid, refill the albuterol)
The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5
weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. His
inhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he should
not be without a prescription for the
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bronchodilator and increasing the steroid, but this is not the best choice because this does not include a
refill of the albuterol and this patient cannot be without access to a rescue inhaler.
Patients with asthma: (can cough or wheeze)
The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied by
episodic wheezing or dyspnea, though some patients with asthma only cough. This is termed “cough
variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of the airways is a
typical finding.
A 26-year-old being treated for community-acquired pneumonia (CAP) has been taking azithromycin
(standard dose) in therapeutic doses for 72 hours. His temperature has gone from 102° F to 101° F.
What should be done? (Stop azithromycin and initiate a respiratory quinolone)
A 26-year-old with CAP should show improvement in symptoms in 24-48 hours if he is on appropriate
antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydophila, but, has
poor Streptococcus coverage. The most likely pathogen in this age group that causes pneumonia is an
atypical pathogen, but at this point the most common typical pathogen, Streptococcus pneumoniae,
must be considered. The best choice is to consider Streptococcus pneumoniae as the pathogen and treat
with a respiratory quinolone. Specifically, this patient should receive a respiratory quinolone because of
the increased incidence of resistant Streptococcus pneumoniae (DRSP).
A 60-year-old patient newly diagnosed with COPD presents to your office. He would like to get the
influenza immunization. He has no evidence of having had the pneumococcal immunization. What
statement is correct? (He should receive both influenza and pneumococcal immunizations today)
This patient has COPD. He should receive the pneumococcal immunization today. He belongs to a group
of patients with chronic illness who are between the ages of 19 and 64 years and so, should be
immunized for pneumonia. The flu immunization should be given to him annually.
Which of the following is NOT part of the differential for a patient who complains of cough? (Obesity)
All of the other conditions listed, heart failure, GERD, and asthma, are associated with cough. Obesity
bronchodilator and increasing the steroid, but this is not the best choice because this does not include a
refill of the albuterol and this patient cannot be without access to a rescue inhaler.
Patients with asthma: (can cough or wheeze)
The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied by
episodic wheezing or dyspnea, though some patients with asthma only cough. This is termed “cough
variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of the airways is a
typical finding.
A 26-year-old being treated for community-acquired pneumonia (CAP) has been taking azithromycin
(standard dose) in therapeutic doses for 72 hours. His temperature has gone from 102° F to 101° F.
What should be done? (Stop azithromycin and initiate a respiratory quinolone)
A 26-year-old with CAP should show improvement in symptoms in 24-48 hours if he is on appropriate
antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydophila, but, has
poor Streptococcus coverage. The most likely pathogen in this age group that causes pneumonia is an
atypical pathogen, but at this point the most common typical pathogen, Streptococcus pneumoniae,
must be considered. The best choice is to consider Streptococcus pneumoniae as the pathogen and treat
with a respiratory quinolone. Specifically, this patient should receive a respiratory quinolone because of
the increased incidence of resistant Streptococcus pneumoniae (DRSP).
A 60-year-old patient newly diagnosed with COPD presents to your office. He would like to get the
influenza immunization. He has no evidence of having had the pneumococcal immunization. What
statement is correct? (He should receive both influenza and pneumococcal immunizations today)
This patient has COPD. He should receive the pneumococcal immunization today. He belongs to a group
of patients with chronic illness who are between the ages of 19 and 64 years and so, should be
immunized for pneumonia. The flu immunization should be given to him annually.
Which of the following is NOT part of the differential for a patient who complains of cough? (Obesity)
All of the other conditions listed, heart failure, GERD, and asthma, are associated with cough. Obesity
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elapsed since the initial one, he should be revaccinated today. Two immunizations are available, PCV13
and PPSV23. He needs both, but PCV13 should be administered today. PPSV23 should be administered at
least 1 year later.
A 24-year-old college student who does not smoke is diagnosed with pneumonia. He is otherwise
healthy and does not need hospitalization at this time. What antibiotic represents the best choice for
treatment for him? (Clarithromycin)
A macrolide (like azithromycin or clarithromycin) or a tetracycline (like doxycycline) is used for initial
treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had
recent antibiotic exposure. These agents are chosen because they cover atypical pathogens (the
organism most likely to have infected him) and provide coverage against nondrug-resistant forms of
Streptococcus. Fluoroquinolones are commonly used first line in these patients. However, guidelines
strongly recommend using fluoroquinolones for patients with comorbidities and/or those who have
suspected macrolide resistant strains of Streptococcus. Inappropriate use of fluoroquinolones will
promote development of fluoroquinolone-resistant pathogens.
What does a peak flow meter measure? (Expiratory flow)
A peak flow meter measures peak expiratory flow; that is, air flow out of a patient’s lungs. Peak flow is
sensitive to changes in the respiratory tubules and so reflects narrowing of the airways. The utility of a
peak flow meter is especially important for patients with asthma because of the rapid changes that occur
prior to the onset of an asthma exacerbation. There is minimal to no benefit of measuring these airway
changes in patients with COPD and pneumonia.
The major laboratory abnormality noted in patients who have pneumococcal pneumonia is:
(leukocytosis)
An increased white count is typical in patients with bacterial pneumonia such as pneumococcal
pneumonia. Eosinophils can be increased in patients who develop pneumonia secondary to exposure to
a very irritating substance like a toxic gas. Gram stain can demonstrate gram-positive or negative
pathogens. Leukopenia is an ominous finding, especially in older patients. This indicates a poor prognosis
because it means that the immune system is not responding to a potentially fatal pathogen.
Which drug class is never used to treat chronic obstructive pulmonary disease (COPD)? (Leukotriene
blockers)
There is no data to suggest efficacy in treating COPD patients with leukotriene blockers like zafirlukast or
montelukast. A long-acting bronchodilator (used twice daily) like salmeterol is commonly used. The long-
acting anticholinergic medication tiotropium can be used once daily. Systemic steroids may be used for
exacerbations of COPD.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has
wheezing and diminished breath sounds in the upper right lobe. His cough is non-productive, and he
denies nasal symptoms. Which symptom is most likely related to pneumonia? (Fever)
The presence of fever should trigger the practitioner to consider pneumonia. The other symptoms are
most likely
elapsed since the initial one, he should be revaccinated today. Two immunizations are available, PCV13
and PPSV23. He needs both, but PCV13 should be administered today. PPSV23 should be administered at
least 1 year later.
A 24-year-old college student who does not smoke is diagnosed with pneumonia. He is otherwise
healthy and does not need hospitalization at this time. What antibiotic represents the best choice for
treatment for him? (Clarithromycin)
A macrolide (like azithromycin or clarithromycin) or a tetracycline (like doxycycline) is used for initial
treatment of uncomplicated pneumonia in outpatients who are otherwise healthy and have not had
recent antibiotic exposure. These agents are chosen because they cover atypical pathogens (the
organism most likely to have infected him) and provide coverage against nondrug-resistant forms of
Streptococcus. Fluoroquinolones are commonly used first line in these patients. However, guidelines
strongly recommend using fluoroquinolones for patients with comorbidities and/or those who have
suspected macrolide resistant strains of Streptococcus. Inappropriate use of fluoroquinolones will
promote development of fluoroquinolone-resistant pathogens.
What does a peak flow meter measure? (Expiratory flow)
A peak flow meter measures peak expiratory flow; that is, air flow out of a patient’s lungs. Peak flow is
sensitive to changes in the respiratory tubules and so reflects narrowing of the airways. The utility of a
peak flow meter is especially important for patients with asthma because of the rapid changes that occur
prior to the onset of an asthma exacerbation. There is minimal to no benefit of measuring these airway
changes in patients with COPD and pneumonia.
The major laboratory abnormality noted in patients who have pneumococcal pneumonia is:
(leukocytosis)
An increased white count is typical in patients with bacterial pneumonia such as pneumococcal
pneumonia. Eosinophils can be increased in patients who develop pneumonia secondary to exposure to
a very irritating substance like a toxic gas. Gram stain can demonstrate gram-positive or negative
pathogens. Leukopenia is an ominous finding, especially in older patients. This indicates a poor prognosis
because it means that the immune system is not responding to a potentially fatal pathogen.
Which drug class is never used to treat chronic obstructive pulmonary disease (COPD)? (Leukotriene
blockers)
There is no data to suggest efficacy in treating COPD patients with leukotriene blockers like zafirlukast or
montelukast. A long-acting bronchodilator (used twice daily) like salmeterol is commonly used. The long-
acting anticholinergic medication tiotropium can be used once daily. Systemic steroids may be used for
exacerbations of COPD.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has
wheezing and diminished breath sounds in the upper right lobe. His cough is non-productive, and he
denies nasal symptoms. Which symptom is most likely related to pneumonia? (Fever)
The presence of fever should trigger the practitioner to consider pneumonia. The other symptoms are
most likely
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A patient with COPD has been using albuterol with good relief for shortness of breath. He is using it 3-
4 times daily over the past 4 weeks. How should the NP manage this? (Add a long-acting beta agonist)
The patient is using albuterol too frequently. It should be used no more than twice weekly because it will
lose its effectiveness over time (tachyphylaxis). Albuterol should be used as a rescue medication only.
This patient’s medication regimen needs adjusting. The best choice is to consider adding a long-acting
beta agonist (or long acting inhaled anticholinergic) and have him use albuterol as a rescue medication
only.
Which of the following may be used to diagnose COPD? (Pulmonary function tests or spirometry)
Spirometry or pulmonary function tests (PFTs) are essential to diagnose COPD. The most important
measures are the FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). Chest
radiograph has a poor sensitivity in diagnosing COPD. Only about half of patients with moderately severe
COPD can be diagnosed using chest radiography alone. CT scan is able to identify emphysema, but not
chronic bronchitis. Arterial blood gases demonstrate hypoxia, but a specific cause is not able to be
determined from this test alone.
A patient with acute bronchitis was diagnosed at an urgent care center 10 days ago. He reports that he
received an antitussive for nighttime cough, a steroid injection and oral steroids, and an antibiotic.
Which of these interventions was of greatest benefit in resolution of his symptoms? (None of them)
Acute bronchitis is almost always due to a viral infection. The antibiotic had no effect in symptom
resolution. Unfortunately, antibiotics are commonly given for acute bronchitis. There is no evidence to
support use of steroids as they do not result in quicker resolution of symptoms than placebo. In fact,
multiple studies have failed to demonstrate benefit. Time is of greatest benefit in resolution of acute
bronchitis symptoms.
A 65-year-old patient has COPD. She receives a prescription for an albuterol inhaler. What medication
information should be provided to this patient? (This may cause tachycardia)
An example of an inhaled beta agonist is albuterol or levalbuterol. These agents stimulate the beta
receptors in the lungs and in the heart. This helps the patient breathe better because it produces
bronchodilation, but it potentially can produce arrhythmias or angina because beta receptors in the
heart can become stimulated too. The dose for a patient with underlying cardiac problems is half the
dose (and used with caution). Common side effects of these agents are jitteriness, tremor, nervousness,
and potentially hypokalemia if used on a regular basis.
A patient presents with symptoms of influenza during influenza season. He has not received the
immunization against influenza. What should be used to help diagnose influenza in him? (A nasal
swab)
Influenza is diagnosed based on the results of a flu swab and the patient’s clinical presentation.
A patient with COPD has been using albuterol with good relief for shortness of breath. He is using it 3-
4 times daily over the past 4 weeks. How should the NP manage this? (Add a long-acting beta agonist)
The patient is using albuterol too frequently. It should be used no more than twice weekly because it will
lose its effectiveness over time (tachyphylaxis). Albuterol should be used as a rescue medication only.
This patient’s medication regimen needs adjusting. The best choice is to consider adding a long-acting
beta agonist (or long acting inhaled anticholinergic) and have him use albuterol as a rescue medication
only.
Which of the following may be used to diagnose COPD? (Pulmonary function tests or spirometry)
Spirometry or pulmonary function tests (PFTs) are essential to diagnose COPD. The most important
measures are the FEV1 (forced expiratory volume in one second) and FVC (forced vital capacity). Chest
radiograph has a poor sensitivity in diagnosing COPD. Only about half of patients with moderately severe
COPD can be diagnosed using chest radiography alone. CT scan is able to identify emphysema, but not
chronic bronchitis. Arterial blood gases demonstrate hypoxia, but a specific cause is not able to be
determined from this test alone.
A patient with acute bronchitis was diagnosed at an urgent care center 10 days ago. He reports that he
received an antitussive for nighttime cough, a steroid injection and oral steroids, and an antibiotic.
Which of these interventions was of greatest benefit in resolution of his symptoms? (None of them)
Acute bronchitis is almost always due to a viral infection. The antibiotic had no effect in symptom
resolution. Unfortunately, antibiotics are commonly given for acute bronchitis. There is no evidence to
support use of steroids as they do not result in quicker resolution of symptoms than placebo. In fact,
multiple studies have failed to demonstrate benefit. Time is of greatest benefit in resolution of acute
bronchitis symptoms.
A 65-year-old patient has COPD. She receives a prescription for an albuterol inhaler. What medication
information should be provided to this patient? (This may cause tachycardia)
An example of an inhaled beta agonist is albuterol or levalbuterol. These agents stimulate the beta
receptors in the lungs and in the heart. This helps the patient breathe better because it produces
bronchodilation, but it potentially can produce arrhythmias or angina because beta receptors in the
heart can become stimulated too. The dose for a patient with underlying cardiac problems is half the
dose (and used with caution). Common side effects of these agents are jitteriness, tremor, nervousness,
and potentially hypokalemia if used on a regular basis.
A patient presents with symptoms of influenza during influenza season. He has not received the
immunization against influenza. What should be used to help diagnose influenza in him? (A nasal
swab)
Influenza is diagnosed based on the results of a flu swab and the patient’s clinical presentation.
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Streptococcus pneumoniae (S. pneumo) is the most common pathogen in community-acquired
pneumonia (CAP) worldwide. It is more common in age extremes (the very young and very old) and
during winter months. Group A Strep can cause a fulminant pneumonia even in patients who are
immunocompetent. Mycoplasma is the most common atypical pathogen that causes pneumonia.
Staphylococcus pneumonia is more common postinfluenza in the very young and very old.
A patient recently received levofloxacin for 7 days to treat pneumonia. His respiratory symptoms have
resolved, but today he calls the office. He reports having severe watery diarrhea, abdominal cramping,
and low-grade fever. What should be done? (Order a stool specimen)
This history of recent antibiotic exposure suggests C. difficile. A stool specimen should be ordered to
assess for infection with C. difficile. Some clinicians will initiate treatment for C. difficile based on this
history, especially if the patient’s symptoms are severe or the patient is elderly/debilitated.
A 20-year-old college age student has a positive TB skin test. Which choice listed below provides
definitive diagnosis of tuberculosis? (A sputum specimen)
Screening for TB is performed with a skin test known as the Mantoux. A chest X-ray is typically
performed after a positive skin test, but is not diagnostic since TB can affect organs other than the lungs.
A sputum specimen is used for definitive diagnosis. A questionnaire is used for screening patients who
have had a history of a positive TB skin test. If symptoms are acknowledged on the questionnaire,
generally, a chest X-ray is performed. The questionnaire is used to prevent too frequent exposure to
radiation in patients in whom regular screening is required, like healthcare providers.
A patient has cough, pharyngitis, nasal discharge, and fever. He has been diagnosed with acute
bronchitis. Which symptom is least likely in the first 3 days of this illness? (Cough)
Cough is the most common symptom associated with acute bronchitis and almost always appears after
day 3 of the illness. In the first few days of acute bronchitis, upper respiratory symptoms predominate. In
fact, it may be impossible to distinguish upper respiratory infection from acute bronchitis. Pharyngitis
and nasal discharge/congestion are common on days 1-3. Acute bronchitis is suggested when cough lasts
longer than 5 days. Fever is a relatively uncommon symptom of acute bronchitis. When fever appears
along with cough, pneumonia should be strongly considered.
Which
Streptococcus pneumoniae (S. pneumo) is the most common pathogen in community-acquired
pneumonia (CAP) worldwide. It is more common in age extremes (the very young and very old) and
during winter months. Group A Strep can cause a fulminant pneumonia even in patients who are
immunocompetent. Mycoplasma is the most common atypical pathogen that causes pneumonia.
Staphylococcus pneumonia is more common postinfluenza in the very young and very old.
A patient recently received levofloxacin for 7 days to treat pneumonia. His respiratory symptoms have
resolved, but today he calls the office. He reports having severe watery diarrhea, abdominal cramping,
and low-grade fever. What should be done? (Order a stool specimen)
This history of recent antibiotic exposure suggests C. difficile. A stool specimen should be ordered to
assess for infection with C. difficile. Some clinicians will initiate treatment for C. difficile based on this
history, especially if the patient’s symptoms are severe or the patient is elderly/debilitated.
A 20-year-old college age student has a positive TB skin test. Which choice listed below provides
definitive diagnosis of tuberculosis? (A sputum specimen)
Screening for TB is performed with a skin test known as the Mantoux. A chest X-ray is typically
performed after a positive skin test, but is not diagnostic since TB can affect organs other than the lungs.
A sputum specimen is used for definitive diagnosis. A questionnaire is used for screening patients who
have had a history of a positive TB skin test. If symptoms are acknowledged on the questionnaire,
generally, a chest X-ray is performed. The questionnaire is used to prevent too frequent exposure to
radiation in patients in whom regular screening is required, like healthcare providers.
A patient has cough, pharyngitis, nasal discharge, and fever. He has been diagnosed with acute
bronchitis. Which symptom is least likely in the first 3 days of this illness? (Cough)
Cough is the most common symptom associated with acute bronchitis and almost always appears after
day 3 of the illness. In the first few days of acute bronchitis, upper respiratory symptoms predominate. In
fact, it may be impossible to distinguish upper respiratory infection from acute bronchitis. Pharyngitis
and nasal discharge/congestion are common on days 1-3. Acute bronchitis is suggested when cough lasts
longer than 5 days. Fever is a relatively uncommon symptom of acute bronchitis. When fever appears
along with cough, pneumonia should be strongly considered.
Which
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Mr. Smith has smoked for 45 years. Which of the following medications may worsen one of his
diseases? (Propanolol)
Propanolol is a nonselective beta blocker and might be potentially more harmful in a patient who has
COPD than a cardioselective beta blocker. Metoprolol is a cardioselective beta blocker. Typically,
cardioselective beta blockers exert their effect on the beta receptors in the heart, but not always.
Sometimes there is effect on the beta receptors in the lungs. This could produce shortness of breath and
would be described as a drug-disease interaction. Noncardioselective beta blockers like propanolol have
a worse effect than cardioselective ones. In any event, beta blocker use should be avoided or used with
caution in patients who have lower airway disease.
The most common sequela of influenza in older adults is: (Pneumonia)
More than 90% of deaths associated with influenza occur in older adults. Pneumonia is the most
common cause of death and most common reason for hospital admission in older patients with
influenza. Annual influenza immunization is recommended for all adults in the United States.
A healthy 7-year-old child is diagnosed with atypical pneumonia. He is febrile but not in distress. What
is the preferred treatment for him? (Azithromycin)
In this age group (> 5 years), the most common atypical pathogens are Mycoplasma or Chlamydophila.
Therefore, a macrolide antibiotic like azithromycin is the preferred agent. It is usually chosen first for its
coverage of atypical pathogens. Doxycycline is not an appropriate choice because it is contraindicated in
children younger than 8 years, however, it does provide coverage against the atypical pathogens.
Amoxicillin provides no coverage of atypical pathogens and so it is a poor choice.
A 30-year-old patient with intermittent asthma
Mr. Smith has smoked for 45 years. Which of the following medications may worsen one of his
diseases? (Propanolol)
Propanolol is a nonselective beta blocker and might be potentially more harmful in a patient who has
COPD than a cardioselective beta blocker. Metoprolol is a cardioselective beta blocker. Typically,
cardioselective beta blockers exert their effect on the beta receptors in the heart, but not always.
Sometimes there is effect on the beta receptors in the lungs. This could produce shortness of breath and
would be described as a drug-disease interaction. Noncardioselective beta blockers like propanolol have
a worse effect than cardioselective ones. In any event, beta blocker use should be avoided or used with
caution in patients who have lower airway disease.
The most common sequela of influenza in older adults is: (Pneumonia)
More than 90% of deaths associated with influenza occur in older adults. Pneumonia is the most
common cause of death and most common reason for hospital admission in older patients with
influenza. Annual influenza immunization is recommended for all adults in the United States.
A healthy 7-year-old child is diagnosed with atypical pneumonia. He is febrile but not in distress. What
is the preferred treatment for him? (Azithromycin)
In this age group (> 5 years), the most common atypical pathogens are Mycoplasma or Chlamydophila.
Therefore, a macrolide antibiotic like azithromycin is the preferred agent. It is usually chosen first for its
coverage of atypical pathogens. Doxycycline is not an appropriate choice because it is contraindicated in
children younger than 8 years, however, it does provide coverage against the atypical pathogens.
Amoxicillin provides no coverage of atypical pathogens and so it is a poor choice.
A 30-year-old patient with intermittent asthma
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very young children, it is also implicated in older adults as a causative agent in pneumonia. In young and
middle adults, Mycoplasma is a common pathogen.
Which medication below should be avoided in a patient with stage 3 COPD? (Cough suppressant with
codeine)
Codeine should be avoided (or used with extreme caution) because the sedative effect of codeine or any
narcotic can potentially worsen respiratory depression and worsen hypercapnia.
A patient with acute bronchitis and cough for 5 days calls to report that his cough is productive of
discolored sputum. He has no other new symptoms. How should the nurse practitioner manage this?
(Continue the original plan of care)
This is the typical course of acute bronchitis. Acute bronchitis is characterized by cough lasting greater
than 5 days, but usually less than 20 days. More than 50% of patients report discolored sputum. Since
the overwhelming majority of cases of acute bronchitis are secondary to viral causes, antibiotics are not
indicated. Discolored sputum is related to sloughing of epithelial cells and is the reason for the
discoloration. Discolored sputum does not indicate bacterial infection. The CDC recommends treating
acute bronchitis with antibiotics ONLY when the etiology is pertussis. In all other cases, the patient
should be treated with supportive and symptomatic management only.
A patient has received a prescription for lisinopril. Which side effect most commonly occurs with this
medication? (Dry cough)
A common side effect of ACE inhibitors is dry cough. Though estimates vary, 5-20% of patients who
receive ACE inhibitors develop a cough. Angiotensin converting enzyme is believed to be responsible for
metabolism of bradykinin in the lungs. Bradykinin is thought to be responsible for the cough because it
induces production of arachidonic acid metabolites and nitric oxide. These substances may promote
cough. The cough associated with ACE inhibitors appears to be a class effect.
A 24-year-old presents with fever, rhinorrhea, and paroxysmal, high-pitched cough. This is: (Pertussis)
Pertussis is also called “whooping cough.” This is a highly communicable respiratory disease caused by
Bordetella pertussis. There are three recognized stages of pertussis: the catarrhal phase, the paroxysmal
phase, and convalescence. More adults than children have contracted pertussis in the last decade. Since
the outbreak of pertussis in Iowa in 2005, diminished titers were recognized and adolescents are being
given a booster with TdaP at 11-12 years of age.
A 60-year-old patient reports chronic cough and sputum production. He has
very young children, it is also implicated in older adults as a causative agent in pneumonia. In young and
middle adults, Mycoplasma is a common pathogen.
Which medication below should be avoided in a patient with stage 3 COPD? (Cough suppressant with
codeine)
Codeine should be avoided (or used with extreme caution) because the sedative effect of codeine or any
narcotic can potentially worsen respiratory depression and worsen hypercapnia.
A patient with acute bronchitis and cough for 5 days calls to report that his cough is productive of
discolored sputum. He has no other new symptoms. How should the nurse practitioner manage this?
(Continue the original plan of care)
This is the typical course of acute bronchitis. Acute bronchitis is characterized by cough lasting greater
than 5 days, but usually less than 20 days. More than 50% of patients report discolored sputum. Since
the overwhelming majority of cases of acute bronchitis are secondary to viral causes, antibiotics are not
indicated. Discolored sputum is related to sloughing of epithelial cells and is the reason for the
discoloration. Discolored sputum does not indicate bacterial infection. The CDC recommends treating
acute bronchitis with antibiotics ONLY when the etiology is pertussis. In all other cases, the patient
should be treated with supportive and symptomatic management only.
A patient has received a prescription for lisinopril. Which side effect most commonly occurs with this
medication? (Dry cough)
A common side effect of ACE inhibitors is dry cough. Though estimates vary, 5-20% of patients who
receive ACE inhibitors develop a cough. Angiotensin converting enzyme is believed to be responsible for
metabolism of bradykinin in the lungs. Bradykinin is thought to be responsible for the cough because it
induces production of arachidonic acid metabolites and nitric oxide. These substances may promote
cough. The cough associated with ACE inhibitors appears to be a class effect.
A 24-year-old presents with fever, rhinorrhea, and paroxysmal, high-pitched cough. This is: (Pertussis)
Pertussis is also called “whooping cough.” This is a highly communicable respiratory disease caused by
Bordetella pertussis. There are three recognized stages of pertussis: the catarrhal phase, the paroxysmal
phase, and convalescence. More adults than children have contracted pertussis in the last decade. Since
the outbreak of pertussis in Iowa in 2005, diminished titers were recognized and adolescents are being
given a booster with TdaP at 11-12 years of age.
A 60-year-old patient reports chronic cough and sputum production. He has
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long-acting, and inhaled steroids, represent the cornerstone of management of most patients who have
asthma. Not all patients with asthma wheeze, therefore, asking that question might not be of great help.
Severity of symptoms is subjective. Smoking cessation is important, but not a determinant in selecting
medications for asthma management.
Breath sounds auscultated over the periphery of the lung fields are quiet and wispy during the
inspiratory phase followed by a short, almost silent expiratory phase. These breath sounds are
considered: (Vesicular)
The three normal breath sounds are vesicular, bronchovesicular, and bronchial. Vesicular breath sounds
consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are
heard over the periphery of the lung fields. Bronchial breath sounds consist of a full inspiratory and
expiratory phase with the inspiratory phase usually being louder. They are normally heard over the
trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened
and softer expiratory phase. They are normally heard over the hilar region. Crackles are adventitious
sounds heard in the lungs and may be due to abnormalities in the lungs.
GI
The two tests that can indicate current infection with hepatitis B are: (presence of hepatitis B surface
antigen and IgM)
The earliest serologic marker that indicates acute hepatitis B infection is the presence of hepatitis B
surface antigen. It becomes positive about 1-10 weeks after infection, but usually before symptom onset.
A positive IgM indicates current infection. The presence of hepatitis B core antibody identifies hepatitis B
infection (present or past) with certainty. It does not indicate timing of infection.
A mother of a 4-week-old infant visits your office. She states that her baby is vomiting after feeding
and then cries as if he is hungry again. What should the nurse practitioner assess? (His abdomen for an
olive shaped mass)
The symptoms likely reflect pyloric stenosis. The most common time for this to occur is 3
long-acting, and inhaled steroids, represent the cornerstone of management of most patients who have
asthma. Not all patients with asthma wheeze, therefore, asking that question might not be of great help.
Severity of symptoms is subjective. Smoking cessation is important, but not a determinant in selecting
medications for asthma management.
Breath sounds auscultated over the periphery of the lung fields are quiet and wispy during the
inspiratory phase followed by a short, almost silent expiratory phase. These breath sounds are
considered: (Vesicular)
The three normal breath sounds are vesicular, bronchovesicular, and bronchial. Vesicular breath sounds
consist of a quiet, wispy inspiratory phase followed by a short, almost silent expiratory phase. They are
heard over the periphery of the lung fields. Bronchial breath sounds consist of a full inspiratory and
expiratory phase with the inspiratory phase usually being louder. They are normally heard over the
trachea and larynx. Bronchovesicular breath sounds consist of a full inspiratory phase with a shortened
and softer expiratory phase. They are normally heard over the hilar region. Crackles are adventitious
sounds heard in the lungs and may be due to abnormalities in the lungs.
GI
The two tests that can indicate current infection with hepatitis B are: (presence of hepatitis B surface
antigen and IgM)
The earliest serologic marker that indicates acute hepatitis B infection is the presence of hepatitis B
surface antigen. It becomes positive about 1-10 weeks after infection, but usually before symptom onset.
A positive IgM indicates current infection. The presence of hepatitis B core antibody identifies hepatitis B
infection (present or past) with certainty. It does not indicate timing of infection.
A mother of a 4-week-old infant visits your office. She states that her baby is vomiting after feeding
and then cries as if he is hungry again. What should the nurse practitioner assess? (His abdomen for an
olive shaped mass)
The symptoms likely reflect pyloric stenosis. The most common time for this to occur is 3
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Initially, pain can be in the general abdomen, then become periumbilical, and finally localize to the lower
right quadrant. Early symptoms are difficult to identify, especially in older adults.
A 70-year-old presents to the nurse practitioner’s office for a well exam today. What medication
probably has no effect on screening for occult blood in the stool? (Acetaminophen)
The exam for occult blood is a screen for colorectal cancer. Aspirin, clopidogrel, NSAIDs, warfarin all
decrease the positive predictive value of the test because they all can exacerbate bleeding if it is
occurring in the colon secondary to a polyp or tumor. Ideally, the medications mentioned (except
acetaminophen) would be stopped prior to the exam to increase the likelihood of test sensitivity, but this
is not always possible.
Symptoms of uncomplicated reflux disease in older adults should be treated: (with empiric treatment)
In older patients without signs of complicated GERD (choking, cough, shortness of breath, pain with
swallowing or in the chest), empiric treatment is appropriate. Empiric treatment can take place using
proton pump inhibitors or H2 blockers. If H2 blockers are used, famotidine and nizatidine are preferred
because of their efficacy and low risk of drug-drug interactions. If symptoms of GERD persist despite
initial treatment, or if symptoms are severe, patients should have testing to rule out esophageal cancer,
Barrett’s esophagitis, or other conditions of the esophagus and throat.
Which symptom is INCONSISTENT with irritable bowel syndrome in older adults? (Onset after 50 years
of age)
Irritable bowel syndrome (IBS) is common in adults and lasts into older adulthood, but symptoms start
prior to age 50 years. Typical symptoms of IBS are diarrhea and constipation intermittently, abdominal
pain (one of the criteria for diagnosis), and bloating. Other symptoms that are inconsistent with IBS are
associated weight loss, blood in the stool, rectal bleeding, and nocturnal diarrhea. These are more
indicative of inflammatory disease or carcinoma of the bowel.
A 20-year-old
Initially, pain can be in the general abdomen, then become periumbilical, and finally localize to the lower
right quadrant. Early symptoms are difficult to identify, especially in older adults.
A 70-year-old presents to the nurse practitioner’s office for a well exam today. What medication
probably has no effect on screening for occult blood in the stool? (Acetaminophen)
The exam for occult blood is a screen for colorectal cancer. Aspirin, clopidogrel, NSAIDs, warfarin all
decrease the positive predictive value of the test because they all can exacerbate bleeding if it is
occurring in the colon secondary to a polyp or tumor. Ideally, the medications mentioned (except
acetaminophen) would be stopped prior to the exam to increase the likelihood of test sensitivity, but this
is not always possible.
Symptoms of uncomplicated reflux disease in older adults should be treated: (with empiric treatment)
In older patients without signs of complicated GERD (choking, cough, shortness of breath, pain with
swallowing or in the chest), empiric treatment is appropriate. Empiric treatment can take place using
proton pump inhibitors or H2 blockers. If H2 blockers are used, famotidine and nizatidine are preferred
because of their efficacy and low risk of drug-drug interactions. If symptoms of GERD persist despite
initial treatment, or if symptoms are severe, patients should have testing to rule out esophageal cancer,
Barrett’s esophagitis, or other conditions of the esophagus and throat.
Which symptom is INCONSISTENT with irritable bowel syndrome in older adults? (Onset after 50 years
of age)
Irritable bowel syndrome (IBS) is common in adults and lasts into older adulthood, but symptoms start
prior to age 50 years. Typical symptoms of IBS are diarrhea and constipation intermittently, abdominal
pain (one of the criteria for diagnosis), and bloating. Other symptoms that are inconsistent with IBS are
associated weight loss, blood in the stool, rectal bleeding, and nocturnal diarrhea. These are more
indicative of inflammatory disease or carcinoma of the bowel.
A 20-year-old
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A healthcare provider (“the HCP”) was stuck with a needle from a patient suspected to be infected
with HIV (“the patient”). A rapid HIV test was performed on the patient and found to be positive. This
means that: (the HIV status of the patient requires further testing)
The rapid HIV is always performed on the source patient (“the patient”). It is known as an ELISA (enzyme
linked immunosorbent assay). In the patient suspected of being HIV positive, it is performed to establish
whether or not he was positive at the time of the needle stick. In this case, it was found to be positive,
but, this is a screening test, and false positives can occur. Therefore, a confirmatory test, the western
blot, is routinely performed on the patient’s specimen to confirm the findings of the ELISA. The
healthcare provider will usually be tested with a rapid HIV but it is done to establish HIV status at the
time of the needlestick. The results of a rapid test can be performed in less than 20 minutes.
A patient has had right upper quadrant pain that has lasted for the past 3 days, but the pain has
become acute in the past 12 hours. He has low-grade fever. Which lab test(s) will be elevated if he has
pancreatitis? (Serum amylase)
Serum amylase levels begin to rise 6-12 hours after pancreatic insult and remain elevated for 3-5 days.
The other tests described may be abnormal but are not specific for pancreatitis.
A patient presents with complaints of bright red stools over the past week. This symptom could be
consistent with: (cancer of the sigmoid colon)
Bright red blood in the stools is more characteristic of left-sided colon cancer (descending and sigmoid
colon) or rectal hemorrhoids. If blood occurs in the
A healthcare provider (“the HCP”) was stuck with a needle from a patient suspected to be infected
with HIV (“the patient”). A rapid HIV test was performed on the patient and found to be positive. This
means that: (the HIV status of the patient requires further testing)
The rapid HIV is always performed on the source patient (“the patient”). It is known as an ELISA (enzyme
linked immunosorbent assay). In the patient suspected of being HIV positive, it is performed to establish
whether or not he was positive at the time of the needle stick. In this case, it was found to be positive,
but, this is a screening test, and false positives can occur. Therefore, a confirmatory test, the western
blot, is routinely performed on the patient’s specimen to confirm the findings of the ELISA. The
healthcare provider will usually be tested with a rapid HIV but it is done to establish HIV status at the
time of the needlestick. The results of a rapid test can be performed in less than 20 minutes.
A patient has had right upper quadrant pain that has lasted for the past 3 days, but the pain has
become acute in the past 12 hours. He has low-grade fever. Which lab test(s) will be elevated if he has
pancreatitis? (Serum amylase)
Serum amylase levels begin to rise 6-12 hours after pancreatic insult and remain elevated for 3-5 days.
The other tests described may be abnormal but are not specific for pancreatitis.
A patient presents with complaints of bright red stools over the past week. This symptom could be
consistent with: (cancer of the sigmoid colon)
Bright red blood in the stools is more characteristic of left-sided colon cancer (descending and sigmoid
colon) or rectal hemorrhoids. If blood occurs in the
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Document Details
University
Chamberlain College of Nursing
Subject
Nursing