AANPCB FNP Exam Questions

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141.

An elderly client from a long-term care facility is brought to the emergency department with second-degree burns covering the entire surface of the bilateral anterior legs and the genitalia. These burns encompass a body surface area of approximately:

  • 19%

  • 18%

  • 10%

  • 4.5%

Correct answer: 19%

According to the rule of nines, each leg accounts for 18% of the Body Surface Area (BSA), and the genitalia accounts for 1% of the BSA. In this client, both legs are burned but only on the front (anterior). In addition, the genitalia was burned.

  • Left leg (anterior): 9%
  • Right leg (anterior): 9%
  • Genitalia: 1%

9 + 9 + 1 = 19%

142.

You have provided counseling for a patient diagnosed with chronic hepatitis B. Which statement made by the patient indicates a need to provide additional education?

  • "I cannot spread the disease since I do not have symptoms."

  • "I will consider getting vaccinated for hepatitis A." 

  • "I should not use medications containing acetaminophen." 

  • "If I become pregnant, my baby should get a hepatitis B virus (HBV) vaccine and HBV immune globulin (HBIG)."

Correct answer: "I cannot spread the disease since I do not have symptoms."

A person with chronic hepatitis B is able to transmit the disease even in the absence of clinical symptoms.

To protect the liver, vaccination for hepatitis A is given to help protect patients from contracting another type of viral hepatitis. Many over-the-counter and prescribed medications are processed in the liver and can cause damage, including medications containing acetaminophen. For women with chronic hepatitis B, in the case of pregnancy, it is important to protect the newborn by giving the Hepatitis B Virus (HBV) vaccine and HBV Immune Globulin (HBIG) immediately after delivery.

143.

When assessing a patient with symptoms, including diarrhea and cramping pain in the left lower quadrant of the abdomen, which of the following findings would help differentiate between a possible diagnosis of acute diverticulitis and diverticulosis?

  • Fever

  • Leukopenia

  • Increased flatulence

  • A pattern of constipation alternating with diarrhea

Correct answer: Fever

In acute colonic diverticulitis, rather than diverticulosis, the diverticula become inflamed, causing fever, leukocytosis (elevated white blood cell count, indicative of inflammation), diarrhea, and left lower quadrant abdominal pain.

Symptoms of diverticulosis include mild left-sided abdominal cramping, increased flatulence, and a pattern of constipation alternating with diarrhea.

144.

A 45-year-old patient has come to the medical clinic reporting episodes of severe vertigo, along with tinnitus and a feeling of pressure affecting the right ear. Subsequent testing indicates Meniere's disease. Which intervention will be incorporated into the treatment plan for this patient related to reducing the severity of an attack?

  • Prescribe an oral antihistamine

  • Prescribe an oral thiazide diuretic

  • Order gentamycin otic drops

  • Order dexamethasone otic drops

Correct answer: Prescribe an oral antihistamine

Meniere's disease is an idiopathic disorder affecting the membranous labyrinth of the ear, causing progressive deafness and attacks of tinnitus and vertigo. Treatment is focused on preventing and decreasing the severity of attacks. An oral antihistamine such as meclizine (Antivert) can decrease vertigo during an episode.

An oral thiazide diuretic can serve to prevent an episode by reducing fluid retention but will not help after an attack is triggered. The disease affects the inner ear, so topical medications (otic drops) are not indicated.

145.

When reviewing the records of a 19-year-old patient, you observe that permethrin is included on the patient's current medication list. 

This medication indicates the presence of which condition?

  • Scabies

  • Psoriasis vulgaris

  • Onychomycosis 

  • Seborrheic dermatitis

Correct answer: Scabies

Permethrin (Elimite, Nix) lotion is the preferred method of treatment for scabies. The lotion should be applied and left on for 8 to 14 hours to be effective and then removed through bathing. Bedclothes and other fabric items should be washed in hot water and placed in a hot clothes dryer afterwards. Alternatively, items can be placed in plastic storage bags for at least 1 week.

In the past, lindane (Kwell) was used, but the use of this product presents potential problems with neurotoxicity, as well as a resulting seizure risk and lower efficacy. In particular, lindane should not be used by pregnant women, children, and elderly patients.

Permethrin is not indicated for psoriasis vulgaris (treatment involves topical corticosteroids), onychomycosis (treatment involves antifungals), or seborrheic dermatitis (treatment involves antifungals).

146.

The 68-year-old female you are examining is complaining of persistent dyspnea even while at rest, dizziness, and you notice she is diaphoretic. She states she has been feeling unusually fatigued for the last few weeks and has been experiencing sleep disturbances.

Based on her symptoms, you intend to treat her for which of the following?

  • Acute coronary syndrome (ACS)

  • Myocardial infarction (MI)

  • Heart failure (HF)

  • Chronic obstructive pulmonary disease (COPD)

Correct answer: Acute coronary syndrome (ACS)

Acute Coronary Syndrome (ACS) and angina result from an inability of the body to supply the myocardium with oxygen sufficient to meet its metabolic demands. This is most often a result of atherosclerosis. Females over the age of 60 years may present with symptoms different from those usually seen in their male counterparts and may describe new or different symptoms such as:

  • Unusual fatigue
  • Sleep disturbances
  • Shortness of breath
  • Indigestion
  • Anxiety

These symptoms may manifest several weeks prior to an acute event. During ACS, women may report:

  • Shortness of breath
  • Weakness
  • Unusual fatigue
  • Diaphoresis
  • Dizziness
  • Chest pain or pressure

Dyspnea in an older female is considered an anginal event.

147.

When performing an early prenatal risk assessment, you recognize all the following as risk factors for preeclampsia except:

  • Low maternal weight

  • Age older than 40 years

  • Collagen vascular disease

  • Primigravida

Correct answer: Low maternal weight

Preeclampsia is a condition found exclusively during the latter half (20 weeks' gestation or greater) of pregnancy or the early postpartum period; it affects about 5% to 8% of all pregnancies. Low maternal weight is not a risk factor for preeclampsia.

Preeclampsia risk factors include:

  • 40 years or older or 16 years or younger
  • First pregnancy (primigravida) or first pregnancy with a new partner
  • Pregestational or Gestational Diabetes Mellitus (GDM)
  • Presence of collagen vascular disease
  • Prepregnancy or primary hypertension
  • Presence of maternal renal disease
  • A family history of Pregnancy-Induced Hypertension (PIH)
  • Multiple gestation pregnancy (multipara)

Additional risk factors include maternal obesity and select autoimmune diseases, including antiphospholipid syndrome and systemic lupus. 

148.

A 38-year-old male has been diagnosed with chronic recurrent paronychia with coexisting onychomycosis and requires removal of the damaged nail. 

What is the most commonly used method of anesthesia for a nail removal procedure?

  • Local ring block

  • General anesthesia

  • Procedural anesthesia

  • Transthecal digital block

Correct answer: Local ring block

Nail removal may be required for treatment of several nail deforming disease processes, such as onychocryptosis (ingrown nail), onychogryphosis (deformed, curved nail), onychomycosis (fungal nail infection), chronic recurrent paronychia and to treat trauma or injury to the nail. Nail removal can be safely undertaken with the use of local anesthesia, although some patients may request general anesthesia for the procedure. Administering a local ring block is commonly used for nail removal and provides adequate local anesthesia to the region to be treated.

Procedural anesthesia, while not required or recommended for nail removal, may need to be considered only if a patient is extremely anxious and unable to sit for the procedure. The administration of a transthecal digital block can also be used for nail removal; however, this is a more specialized nerve block and requires additional training.

149.

A nurse practitioner (NP) is examining an overweight 48-year-old female patient who presented with a sudden onset of epigastric postprandial pain and has a positive Collin's sign. Which of the following diagnoses is most appropriate for this patient? 

  • Cholelithiasis

  • Peptic ulcer disease

  • Acute cholecystitis

  • Appendicitis

Correct answer: Cholelithiasis

Cholelithiasis is most commonly identified in overweight, middle-aged female patients who have a history of hyperlipidemia and eat a high-glycemic diet. Pregnant women and women who have recently experienced significant rapid weight loss are also frequently diagnosed with cholelithiasis. Gallstones form when bile produced by the liver becomes very saturated and precipitates out of solution, forming crystals that become trapped in the mucosa of the gallbladder, forming sludge. This process continues over time, eventually forming larger stones that can then cause symptoms. Most gallstones are comprised of cholesterol. 

Most patients with cholelithiasis are asymptomatic (75%); about 10% to 25% will develop symptoms over the next 10 years. Patients who develop symptoms related to cholelithiasis tend to experience symptoms intermittently. They often report a sudden onset of postprandial pain in the epigastric area or right upper quadrant. They may also report pain that radiates to the tip of the right scapula. This radiating pain is referred to as Collin's sign in honor of Dr. Paddy Collins, who noted that patients frequently attempted to explain their pain by putting one of their hands behind their back and pointing their thumb upwards to the tip of the right scapula. 

Acute cholecystitis typically presents with right upper quadrant or epigastric pain coupled with fever and/or vomiting. Murphy's sign is often present with acute cholecystitis (inspiratory arrest with palpation of the right upper quadrant); 25% to 50% of patients may also have jaundice. Acute appendicitis and peptic ulcer disease may also cause symptoms similar to those of acute cholecystitis.  

150.

A 60-year-old male patient presents to the urgent care center with symptoms, including crampy abdominal pain extending to beneath the right shoulder blade. Other symptoms include burping, diarrhea, nausea, and indigestion.

All the following factors are consistent with an increased risk for gallstone formation except:

  • Male gender

  • Older than 50 years

  • Hyperlipidemia

  • Rapid weight loss

Correct answer: Male gender

Major risk factors for the development of cholelithiasis (gallstones) include:

  • Older than 50
  • Female gender
  • Obesity
  • Hyperlipidemia
  • Rapid weight loss
  • Pregnancy
  • Genetic factors
  • European or Native American ancestry
  • Ingestion of a diet with a high glycemic index

151.

You know that to diagnose primary headache in your 32-year-old patient, you will:

  • Need to exclude other disease processes 

  • Need to identify the associated disease process

  • Need to determine that this is the first headache your patient has experienced

  • Need to identify a recent viremia

Correct answer: Need to exclude other disease processes 

There are two categories of headache types:

  • Primary headaches include migraines, tension-type headaches, and cluster headaches. Primary headaches are not associated with other diseases and likely result from a complex interplay of genetic, developmental, and environmental risk factors.
  • Secondary headaches are associated with or are caused by an intracranial issue, such as viremia, brain tumor, intracranial bleeding, inflammation, or any condition that causes increased intracranial pressure. Secondary headaches typically do not resolve until the underlying illness or condition is identified and treated.

A headache that is the first headache in an adult over the age of 30 years is more likely to be a secondary headache.

152.

You are performing a routine examination on the four-day-old breastfeeding infant of a primipara. The infant has had five wet diapers in the preceding 24 hours, passed four quarter-sized stools that the mother describes as "mustard-colored" in appearance, and has regained 1 oz. of weight since being discharged from the hospital 48 hours ago. The infant's mother verbalizes concern she is not producing enough breastmilk as her baby is requesting very frequent feedings and is considering offering formula supplementation to increase her baby's daily caloric intake.

You know the average required caloric intake for an infant under three months old is:

  • 100-120 kcal/kg/day and discourage formula supplementation, as it will delay and reduce breast milk production.

  • 100-120 kcal/kg/day and recommend starting formula supplementation with 20 mL three times per day until her mature milk comes in.

  • 80-100 kcal/kg/day and discourage formula supplementation, as it will delay and reduce breast milk production.

  • 80-100 kcal/kg/day and recommend starting formula supplementation with 20 mL three times per day until her mature milk comes in.

Correct answer: 100-120 kcal/kg/day and discourage formula supplementation, as it will delay and reduce breast milk production.

Breastfeeding is the sole ideal form of nutrition during infancy, and healthcare providers can help support and influence successful breastfeeding.

To promote milk production and prevent delay of mature milk production and prevent interference with the newborn feeding drive, supplementation with sugar water, formula, or other agents should be discouraged. Frequent breastfeeding is a normal part of healthy breastfeeding in the first few months of life.

The average required caloric intake for a full-term infant younger than three months is 100-120 kcal/kg/day.

153.

A 22-year-old college student presented to the on-campus clinic with a five-day history of headache, body aches, malaise, sore throat, and loss of appetite. On exam, the patient is noted to be febrile and to have enlarged tonsils, as well as marked lymphadenopathy of the anterior and posterior cervical chains. A rapid strep test was negative; Monospot test was positive. The patient verbalized anxiety when informed of the possible mononucleosis diagnosis and wanted to know if he was at risk of dying from the illness. Which of the following complications associated with mononucleosis infection is most likely to cause death in an infected patient?

  • Splenic rupture

  • Airway obstruction

  • Sepsis

  • Pericarditis

Correct answer: Splenic rupture

Mononucleosis is an acute viral illness most commonly caused by infection with the Epstein-Barr Virus (EBV). EBV most commonly affects individuals under the age of 35 years and is spread through contact with saliva or other bodily secretions, including blood and semen. The virus can also be spread through organ transplants and blood transfusions. Over 90% of the world's population has been infected with EBV at some point, although most individuals remain asymptomatic. Once an individual has been exposed to EBV, an incubation period of 30 to 50 days is required before symptoms of infection may develop.

Individuals who go on to develop mononucleosis after being exposed to EBV typically report early symptoms of headache, general malaise, myalgia, and loss of appetite three to five days before full symptoms develop. Fatigue, pharyngitis with enlarged tonsils and exudate on the pharynx and/or tonsils, fever, headache, and marked lymphadenopathy of the anterior and posterior cervical chains persist for five to 15 days. Enlargement of the spleen occurs in approximately 50% of patients, and liver enlargement affects approximately 10% of patients. Fewer than 1% of patients who are diagnosed with mononucleosis will go on to die from complications related to the illness. Airway obstruction caused by enlarged tonsils, sepsis, pericarditis, and splenic rupture may all contribute to death, but the risk of death from splenic rupture is of greatest concern. Atraumatic splenic rupture is rare (0.1% to 0.5%) but often fatal. The greatest risk of splenic rupture is for patients who participate in contact sports or other activities during which they may experience abdominal trauma. 

154.

You are performing an examination of a patient with a diagnosis of gastroesophageal reflux disease (GERD). The emergence of symptoms that would warrant a referral to gastroenterology includes which of the following?

  • Dysphagia 

  • Dyspepsia

  • Postprandial fullness

  • Hoarseness and nocturnal coughing

Correct answer: Dysphagia 

"Alarm" symptoms in GastroEsophageal Reflux Disease (GERD) that warrant a referral to gastroenterology include:

  • Dysphagia (difficulty swallowing)
  • Odynophagia (painful swallowing)
  • Gastrointestinal bleeding
  • Unexplained weight loss
  • Persistent chest pain

Dyspepsia, postprandial fullness, nocturnal cough, and hoarseness are typical findings in GERD and are usually not reasons for alarm.

155.

When performing an examination of a patient following the treatment plan for the relief of hemorrhoids, all the following findings warrant prompt referral for a colonoscopy except:

  • The presence of visible bright red blood on the stool

  • Persistent rectal bleeding 

  • Dark blood mixed with stool

  • The development of anemia related to rectal bleeding 

Correct answer: The presence of visible bright red blood on the stool

Rectal bleeding associated with hemorrhoids is typically described as the presence of visible bright red blood on the stool. This finding does not warrant prompt referral for a colonoscopy.

Reports of persistent bleeding, dark blood mixed with stool, or the development of anemia related to rectal bleeding warrant prompt referral for colonoscopy for an evaluation for colorectal cancer or alternative diagnoses.

156.

A patient is receiving acyclovir (Zovirax) for the suppression of an initial outbreak of genital herpes. Which of the following statements made by the patient indicates the need for further education?

  • "Once my symptoms are gone, I will no longer need to worry about infecting someone else."

  • "This medication may cause me to be nauseated and throw up."

  • "If the infection comes back, there may not be any symptoms."

  • "I should let you know if I get ulcers or white spots inside my mouth while on this medication."

Correct answer: "Once my symptoms are gone, I will no longer need to worry about infecting someone else."

In genital herpes, even when signs or symptoms are absent, genital shedding of the virus occurs for 5% to 20% of days in individuals with long-term infection. The genital herpes virus can be shed from skin that is intact and appears normal. Transmission of genital herpes most often occurs from an infected partner who does not have a visible sore and may not know that they are infected.

Nausea and vomiting are common side effects of acyclovir (Zovirax). 

Recurring outbreaks do not always cause recognizable signs and symptoms. 

The patient should alert the primary care provider about side effects of medication or complications of infection such as sores, ulcers, or white spots on the tongue or inside the mouth, and pain in the gums.

157.

You are reviewing laboratory results with your 67-year-old male diabetic patient after completing his annual exam. His fasting blood sugar and hemoglobin A1c are maintained within an acceptable range at 85 mg/dL and 6.3% respectively on his current doses of metformin and glipizide. His cholesterol and low-density lipoprotein-C (LDL-C) levels are both elevated at 289 mg/dL and 102 mg/dL respectively, while his high-density lipoprotein (HDL) level is low at 25 mg/dL.

Based on recommendations from the American College of Cardiology (ACC) and the American Heart Association (AHA), what medication(s) should be included in his treatment plan?

  • Atorvastatin (Lipitor) 20 mg

  • Atorvastatin (Lipitor) 40 mg

  • Simvastatin (Zocor) 10 mg

  • Rosuvastatin (Crestor) 20 mg

Correct answer: Atorvastatin (Lipitor) 20 mg

The American College of Cardiology (ACC) and the American Heart Association (AHA) have updated their recommendations on the use of statins in the treatment of hyperlipidemia. For diabetic patients between the ages of 40 and 75 years with a low-density lipoprotein-C (LDL-C) level between 70-189 mg/dL, treatment with a moderate-intensity statin such as atorvastatin (Lipitor) 10-20 mg is recommended. Other moderate-intensity statins include simvastatin (Zocor, FloLipid) 20-40 mg, pravastatin (Pravachol) 40-80 mg, and rosuvastatin (Crestor) 5-10 mg.

The use of high-intensity statins is recommended for individuals who have clinical AtheroSclerotic CardioVascular Disease (ASCVD) and are under 75 years of age, have an LDL-C of 190 mg/dL or more, or who have a 10-year estimated ASCVD risk ≥ 7.5%. Examples of high-intensity statins include atorvastatin (Lipitor) 40-80 mg and rosuvastatin (Crestor) 20-40 mg.

Since the patient has an LDL-C of 102 mg/dL (between 70 and 189 mg/dL), moderate-intensity statin therapy is indicated. Atorvastatin (Lipitor) 20 mg is the correct choice. The other answer choices are high-intensity statins (Atorvastatin 40 mg and Rosuvastatin 20 mg), and Simvastatin 10 mg is a low-intensity statin.

158.

You have collected a urine sample via the "clean catch" method from your patient, and you are preparing to perform microscopy to examine the sample. Which of the following common urine sediment microscopic findings, if identified in small numbers, may be found in healthy individuals?

  • Hyaline casts

  • Waxy casts

  • Granular casts

  • Fatty casts

Correct answer: Hyaline casts

The urine sediment can be examined through microscopy to aid in determining the renal and urinary health of an individual. Casts, crystals, mucus, red and white blood cells, epithelial cells (from both the skin and the renal tubules), bacteria, and yeast may all be found in urine sediment samples.

Urinary casts are formed by the solidification of proteins in the tubules and vary in size and shape depending upon where in the tubule they were formed. Hyaline casts are the most frequently noted of the urinary casts and may be found in healthy individuals. Large numbers of hyaline casts in a sample may be indicative of dehydration, excessive exercise, the use of diuretics, or certain renal diseases.

Waxy casts are found in the urine sediment samples of individuals with advanced renal disease or chronic renal failure. Granular casts are found in several types of renal disease and may be an indicator of a significant renal disease. Fatty casts are found in individuals who have lipids in their urine, typically secondary to diabetes or as a complication of nephrotic syndrome.

159.

You are reviewing the abdominal radiograph (x-ray) of a 60-year-old female who has presented to the emergency department with complaints of intermittent crampy abdominal pain, increasing abdominal distention, and bilious emesis. The patient reports a history of five previous abdominal and pelvic surgeries.

Abdominal x-ray findings that are consistent with small bowel obstruction include all the following except:

  • A bowel larger than 10 cm

  • A bowel larger than 3 cm

  • Loops of small bowel positioned in the center of the abdomen

  • A string-of-beads sign

Correct answer: A bowel larger than 10 cm

Small bowel obstruction may be caused by a volvulus, adhesions due to previous abdominal or pelvic surgery (or multiple surgeries), radiation treatment, presence of a foreign body or mass, a history of malignancy, or strangulated hernia. Small bowel obstruction may be identified with the assistance of several imaging studies; however, a plain x-ray should be completed first.

X-ray findings of small bowel obstruction may include:

  • a bowel larger than 3 cm (not larger than 10 cm)
  • loops of the small bowel positioned in the center of the abdomen
  • a string-of-beads sign caused by an increase in peristaltic activity
  • the presence of gas and/or fluid in the loops of distended small bowel
  • an increase in the size of bowel loops proximal to the obstruction and normal-sized bowel loops distal to the obstruction
  • If there is fluid in the distended loops of the bowel, they may appear as elongated soft-tissue masses.
  • massive dilation of the small bowel if the obstruction has been chronic (may appear to be the colon)
  • Air-filled loops will present anteriorly, and fluid-filled loops present posteriorly when the patient is positioned supine.

160.

When formulating a treatment plan for a patient with deep vein thrombosis (DVT), you recognize that all the following are examples of low-molecular-weight heparin except:

  • Rivaroxaban (Xarelto)

  • Enoxaparin (Lovenox)

  • Dalteparin (Fragmin)

  • Ardeparin (Normiflo)

Correct answer: Rivaroxaban (Xarelto)

Current DVT guidelines favor the use of the Direct Oral AntiCoagulants (DOACs) as first-line therapy in many individuals. DOACs consist of oral products, including direct factor Xa inhibitors and the direct thrombin inhibitor dabigatran (Pradaxa). Both are effective for treatment of DVT and Pulmonary Embolus (PE). Rivaroxaban (Xarelto) is an oral factor Xa inhibitor used for long-term anticoagulation.

The use of DOACs has limited, but not eliminated, the use of heparin in DVT therapy, which continues to be used instead of a DOAC when DOAC therapy is contraindicated. Heparin is given parenterally, inhibiting the activity of numerous coagulating factors; its effect on thrombus formation is immediate. 

Low-molecular-weight heparin (LMWH) examples include enoxaparin (Lovenox), dalteparin (Fragmin), and ardeparin (Normiflo), all of which are given via subcutaneous injection.