Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs- Test Bank

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Advanced Assessment Interpreting Findings 3rd Edition Goolsby Grubbs- Test Bank

Chapter 2. An Overview of Genetic Assessment

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____       1.   The first step in the genomic assessment of a patient is obtaining information regarding:

A. Family history
B. Environmental exposures
C. Lifestyle and behaviors
D. Current medications

 

 

____       2.   An affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained is called a(n):

A. Consultand
B. Consulband
C. Index patient
D. Proband

 

 

____       3.   An autosomal dominant disorder involves the:

A. X chromosome
B. Y chromosome
C. Mitochondrial DNA
D. Non-sex chromosomes

 

 

____       4.   To illustrate a union between two second cousin family members in a pedigree, draw:

A. Arrows pointing to the male and female
B. Brackets around the male and female
C. Double horizontal lines between the male and female
D. Circles around the male and female

 

 

____       5.   To illustrate two family members in an adoptive relationship in a pedigree:

A. Arrows are drawn pointing to the male and female
B. Brackets are drawn around the male and female
C. Double horizontal lines are drawn between the male and female
D. Circles are drawn around the male and female

 

 

____       6.   When analyzing the pedigree for autosomal dominant disorders, it is common to see:

A. Several generations of affected members
B. Many consanguineous relationships
C. More members of the maternal lineage affected than paternal
D. More members of the paternal lineage affected than maternal

 

 

____       7.   In autosomal recessive (AR) disorders, individuals need:

A. Only one mutated gene on the sex chromosomes to acquire the disease
B. Only one mutated gene to acquire the disease
C. Two mutated genes to acquire the disease
D. Two mutated genes to become carriers

 

 

____       8.   In autosomal recessive disorders, carriers have:

A. Two mutated genes; one from each parent that cause disease
B. A mutation on a sex chromosome that causes a disease
C. A single gene mutation that causes the disease
D. One copy of a gene mutation but not the disease

 

 

____       9.   With an autosomal recessive disorder, it is important that parents understand that if they both carry a mutation, the following are the risks to each of their offspring (each pregnancy):

A. 50% chance that offspring will carry the disease
B. 10% chance of offspring affected by disease
C. 25% chance children will carry the disease
D. 10% chance children will be disease free

 

 

____     10.   A woman with an X-linked dominant disorder will:

A. Not be affected by the disorder herself
B. Transmit the disorder to 50 % of her offspring (male or female)
C. Not transmit the disorder to her daughters
D. Transmit the disorder to only her daughters

 

 

____     11.   In creating your female patient’s pedigree, you note that she and both of her sisters were affected by the same genetic disorder. Although neither of her parents had indications of the disorder, her paternal grandmother and her paternal grandmother’s two sisters were affected by the same condition. This pattern suggests:

A. Autosomal dominant disorder
B. Chromosomal disorder
C. Mitochondrial DNA disorder
D. X-linked dominant disorder

 

 

____     12.   A woman affected with an X-linked recessive disorder:

A. Has one X chromosome affected by the mutation
B. Will transmit the disorder to all of her children
C. Will transmit the disorder to all of her sons
D. Will not transmit the mutation to any of her daughters

 

 

____     13.   Which of the following are found in an individual with aneuploidy?

A. An abnormal number of chromosomes
B. An X-linked disorder
C. Select cells containing abnormal-appearing chromosomes
D. An autosomal recessive disorder

 

 

____     14.   The pedigree of a family with a mitochondrial DNA disorder is unique in that:

A. None of the female offspring will have the disease
B. All offspring from an affected female will have disease
C. None of the offspring of an affected female will have the disease
D. All the offspring from an affected male will have disease

 

 

____     15.   Which population is at highest risk for the occurrence of aneuploidy in offspring?

A. Mothers younger than 18
B. Fathers younger than 18
C. Mothers over age 35
D. Fathers over age 35

 

 

____     16.   Approximately what percentage of cancers is due to a single-gene mutation?

A. 50% to 70%
B. 30% to 40%
C. 20% to 25%
D. 5% to 10%

 

 

____     17.   According to the Genetic Information Nondiscrimination Act (GINA):

A. NPs should keep all genetic information of patients confidential
B. NPs must obtain informed consent prior to genetic testing of all patients
C. Employers cannot inquire about an employee’s genetic information
D. All of the above

 

 

____     18.   The leading causes of death in the United States are due to:

A. Multifactorial inheritance
B. Single gene mutations
C. X-linked disorders
D. Aneuploidy

 

 

____     19.   Which of the following would be considered a “red flag” that requires more investigation in a patient assessment?

A. Colon cancer in family member at age 70
B. Breast cancer in family member at age 75
C. Myocardial infarction in family member at age 35
D. All of the above

 

 

____     20.   When patients express variable forms of the same hereditary disorder, this is due to:

A. Penetrance
B. Aneuploidy
C. De novo mutation
D. Sporadic inheritance

 

 

____     21.   Your 2-year-old patient shows facial features, such as epicanthal folds, up-slanted palpebral fissures, single transverse palmar crease, and a low nasal bridge. These are referred to as:

A. Variable expressivity related to inherited disease
B. Dysmorphic features related to genetic disease
C. De novo mutations of genetic disease
D. Different penetrant signs of genetic disease

 

 

____     22.   In order to provide a comprehensive genetic history of a patient, the NP should:

A. Ask patients to complete a family history worksheet
B. Seek out pathology reports related to the patient’s disorder
C. Interview family members regarding genetic disorders
D. All of the above

 

Chapter 2. An Overview of Genetic Assessment

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:   A

A critical first step in genomic assessment, including assessment of risk, is the use of family history. Family history is considered the first genetic screen (Berry & Shooner 2004) and is a critical component of care because it reflects shared genetic susceptibilities, shared environment, and common behaviors (Yoon, Scheuner, & Khoury 2003).

 

PTS:    1

 

  1. ANS:   D

A proband is defined as the affected individual who manifests symptoms of a particular condition through whom a family with a genetic disorder is ascertained (Pagon et al. 1993–2013). The proband is the affected individual that brings the family to medical attention.

 

PTS:    1

 

  1. ANS:   D

Autosomal dominant (AD) inheritance is a result of a gene mutation in one of the 22 autosomes.

 

PTS:    1

 

  1. ANS:   C

A consanguineous family is related by descent from a common ancestry and is defined as a “union between two individuals who are related as second cousins or closer” (Hamamy 2012). Consanguinity, if present in the family history, is portrayed using two horizontal lines to establish the relationship between the male and female partners.

 

PTS:    1

 

  1. ANS:   B

For adopted members of the family, use brackets as the appropriate standardized pedigree symbol ([e.g., brackets]).

 

PTS:    1

 

  1. ANS:   A

Pedigrees associated with autosomal dominant (AD) disorders typically reveal multiple affected family members with the disease or syndrome. When analyzing the pedigree for AD disorders or syndromes, it is common to see a “vertical” pattern denoting several generations of affected members.

 

PTS:    1

 

  1. ANS:   C

In autosomal recessive (AR) disorders, the offspring inherits the condition by receiving one copy of the gene mutation from each of the parents. Autosomal recessive disorders must be inherited through both parents (Nussbaum et al. 2007). Individuals who have an AR disorder have two mutated genes, one on each locus of the chromosome. Parents of an affected person are called carriers because each carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease.

 

PTS:    1

 

  1. ANS:   D

Individuals who have an AR disorder have two mutated genes, one on each allele of the chromosome. Parents of an affected person are called carriers because each parent carries one copy of the mutation on one chromosome and a normal gene on the other chromosome. Carriers typically are not affected by the disease. In pedigrees with an AR inheritance patterns, males and females will be equally affected because the gene mutation is on an autosome.

 

PTS:    1

 

  1. ANS:   A

It is important that parents understand that if they both carry a mutation, the risk to each of their offspring (each pregnancy) is an independent event: 25% disease free, 25% affected, and 50% carrier.

 

PTS:    1

 

  1. ANS:   B

Everyone born with an X-linked dominant disorder will be affected with the disease. Transmission of the disorder to the next generation varies by gender, however. A woman will transmit the mutation to 50% of all her offspring (male or female).

 

PTS:    1

 

  1. ANS:   D

A man with an X-linked dominant disorder will transmit the mutation to 100% of his daughters (they receive his X chromosome) and none of his sons (they receive his Y chromosome). The pedigree of a family with an X-linked dominant disorder would reveal all the daughters and none of the sons affected with the disorder if the father has an X-linked disorder.

 

PTS:    1

 

  1. ANS:   C

An X-linked recessive disorder means that in a woman, both X chromosomes must have the mutation if she is to be affected. Because males have only one copy of the X chromosome, they will be affected if their X chromosome carries the mutation.

 

PTS:    1

 

  1. ANS:   A

An individual with an abnormal number of chromosomes has a condition called aneuploidy, which is frequently associated with mental problems or physical problems or both (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007).

 

PTS:    1

 

  1. ANS:   B

Mitochondrial DNA is inherited from the ovum and, therefore, from the mother. The pedigree of a family with a mitochondrial DNA disorder is unique in that all offspring (regardless of gender) of an affected female will have the disease, and none of the offspring from an affected male will have the disease.

 

PTS:    1

 

  1. ANS:   C

Some individuals or couples have unique identifiable risks that should be discussed prior to conception whenever possible. For example, women who will be 35 years of age or older at delivery (advanced maternal age) are at increased risk for aneuploidy.

 

PTS:    1

 

  1. ANS:   D

The majority of cancers are sporadic or multifactorial due to a combination of genetic and environmental factors; however, approximately 5% to 10% of all cancers are due to a single-gene mutation (Garber & Offit 2005).

 

PTS:    1

 

  1. ANS:   D

On May 21, 2008, President George W. Bush signed the Genetic Information Nondiscrimination Act (GINA) to protect Americans against discrimination based upon their genetic information when it comes to health insurance and employment, paving the way for patient personalized genetic medicine without fear of discrimination (National Human Genome Research Institute 2012).

 

PTS:    1

 

  1. ANS:   A

Most disease-causing conditions are not due to a single-gene disorder but are due to multifactorial inheritance, a result of genomics and environmental or behavioral influences. In fact, the leading causes of mortality in the United States—heart disease, cerebrovascular disease, diabetes, and cancer—are all multifactorial. Most congenital malformation, hypertension, arthritis, asthma, obesity, epilepsy, Alzheimer’s, and mental health disorders are also multifactorial.

 

PTS:    1

 

  1. ANS:   C

Early onset cancer syndromes, heart disease, or dementia are red flags that warrant further investigation regarding hereditary disorders.

 

PTS:    1

 

  1. ANS:   A

Some disorders have a range of expression from mild to severe. This variability is referred to as the penetrance of genetic disease. For example, patients with neurofibromatosis (NF1), an AD disorder of the nervous system, may manifest with many forms of the disease. For instance, some patients with NF1 may have mild symptoms, like café-au-lait spots or freckling on the axillary or skin, while others may have life-threatening spinal cord tumors or malignancy (Jorde, Carey, & Bamshad 2010; Nussbaum et al. 2007).

 

PTS:    1

 

  1. ANS:   B

Assessing for dysmorphic features may enable identification of certain syndromes or genetic or chromosomal disorders (Jorde, Carey, & Bamshad 2010; Prichard & Korf 2008). Dysmorphology is defined as “the study of abnormal physical development” (Jorde, Carey, & Bamshad 2010, 302).

 

PTS:    1

 

  1. ANS:   D

Asking the patient to complete a family history worksheet prior to the appointment saves time in the visit while offering the patient an opportunity to contribute to the collection of an accurate family history. Reviewing the family information can also help establish family rapport while verifying medical conditions in individual family members. If a hereditary condition is being considered but family medical information is unclear or unknown, requesting medical records and pathology or autopsy reports may be warranted.

 

PTS:    1

Chapter 10. Abdomen

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____       1.   When performing abdominal assessment, the clinician should perform examination techniques in the following order:

A. Inspection, palpation, percussion, and auscultation
B. Inspection, percussion, palpation, and auscultation
C. Inspection, auscultation, percussion, and palpation
D. Auscultation, palpation, percussion, and inspection

 

 

____       2.   The clinician should auscultate the abdomen to listen for possible bruits of the:

A. Aorta
B. Renal artery
C. Iliac artery
D. All of the above

 

 

____       3.   On abdominal examination, which of the following is assessed using percussion?

A. Liver
B. Kidneys
C. Pancreas
D. Esophagus

 

 

____       4.   In abdominal assessment, a digital rectal examination is performed to assess for:

A. Hemorrhoids
B. Prostate size
C. Blood in stool
D. Ureteral stenosis

 

 

____       5.   Rebound tenderness of the abdomen is a sign of:

A. Constipation
B. Peritoneal inflammation
C. Elevated venous pressure
D. Peritoneal edema

 

 

____       6.   While assessing the abdomen, the clinician deeply palpates the left lower quadrant of the abdomen, and this causes pain in the patient’s right lower abdomen. This is most commonly indicative of:

A. Constipation
B. Diverticulitis
C. Appendicitis
D. Hepatitis

 

 

____       7.   Your patient complains of severe right lower quadrant abdominal pain. To assess the patient for peritoneal inflammation, the examiner should:

A. Percuss the right lower quadrant of the abdomen
B. Deeply palpate the right lower quadrant of the abdomen
C. Auscultate the right lower quadrant for hyperactive bowel sounds
D. Strike the plantar surface of the patient’s heel while the patient is supine

 

 

____       8.   Your patient is lying supine and you ask him to raise his leg while you place resistance against the thigh. The examiner is testing the patient for:

A. Psoas sign
B. Obturator sign
C. Rovsing’s sign
D. Murphys’ sign

 

 

____       9.   A patient is lying supine and the clinician deeply palpates the right upper quadrant of the abdomen while the patient inhales. The examiner is testing the patient for:

A. Psoas sign
B. Obturator sign
C. Rovsing’s sign
D. Murphys’ sign

 

 

____     10.   Your patient has abdominal pain, and it is worsened when the examiner rotates the patient’s right hip inward with the knee bent and the obturator internus muscle is stretched. This is a sign of:

A. Diverticulitis
B. Cholecystitis
C. Appendicitis
D. Mesenteric adenitis

 

 

____     11.   On abdominal examination as the clinician presses on the right upper quadrant to assess liver size, jugular vein distension becomes obvious. Hepatojugular reflux is indicative of:

A. Acute hepatitis
B. Right ventricular failure
C. Cholecystitis
D. Left ventricular failure

 

 

____     12.   Your patient demonstrates positive shifting dullness on percussion of the abdomen. This is indicative of:

A. Cholecystitis
B. Appendicitis
C. Ascites
D. Hepatitis

 

 

____     13.   Your 44-year-old female patient complains of right upper quadrant pain. Her skin and sclera are yellow, and she has hyperbilirubinemia and elevated liver enzymes. The clinician should suspect:

A. Acute pancreatitis
B. Biliary duct obstruction
C. Acute hepatitis
D. Atypical appendicitis

 

 

____     14.   The most common cause of acute pancreatitis is:

A. Trauma
B. Hepatitis virus A
C. Hyperlipidemia
D. Alcohol abuse

 

 

____     15.   Your patient with pancreatitis has a Ranson rule score of 8. The clinician should recognize that this is a risk of:

A. Pleural involvement
B. Alcoholism
C. High mortality
D. Bile duct obstruction

 

 

____     16.   Your patient complains of left upper quadrant pain, fever, extreme fatigue, and spontaneous bruising. The clinician should recognize that these symptoms are often related to:

A. Hematopoetic disorders
B. Hepatomegaly
C. Esophageal varices
D. Pleural effusion

 

 

____     17.   A 16-year-old patient presents with sore throat, cervical lymphadenopathy, fever, extreme fatigue, and left upper quadrant pain. The physical examination reveals splenomegaly. The clinician should recognize the probability of:

A. Bacterial endocarditis
B. Infectious mononucleosis
C. Pneumonia with pleural effusion
D. Pancreatic cancer

 

 

____     18.   Your patient complains of lower abdominal pain, anorexia, extreme fatigue, unintentional weight loss of 10 pounds in last 3 weeks, and you find a positive hemoccult on digital rectal examination. Laboratory tests show iron deficiency anemia. The clinician needs to consider:

A. Diverticulitis
B. Appendicitis
C. Colon cancer
D. Peptic ulcer disease

 

 

____     19.   Which of the following is the most common cause of heartburn-type epigastric pain?

A. Decreased lower esophageal sphincter tone
B. Helicobacteria pylori infection of stomach
C. Esophageal spasm
D. Excess use of NSAIDs

 

 

____     20.   A 22-year-old female enters the emergency room with complaints of right lower quadrant abdominal pain, which has been worsening over the last 24 hours. On examination of the abdomen, there is a palpable mass and rebound tenderness over the right lower quadrant. The clinician should recognize the importance of:

A. Digital rectal examination
B. Endoscopy
C. Ultrasound
D. Pelvic examination

 

 

____     21.   The major sign of ectopic pregnancy is:

A. Sudden onset of severe epigastric pain
B. Amenorrhea with unilateral lower quadrant pain
C. Lower back and rectal pain
D. Palpable abdominal mass

 

 

____     22.   When ruptured ectopic pregnancy is suspected, the following procedure is most important:

A. Culdocentesis
B. CT scan
C. Abdominal x-ray
D. Digital rectal examination

 

 

____     23.   The majority of colon cancers are located in the:

A. Transverse colon
B. Cecum
C. Rectosigmoid region
D. Ascending colon

 

 

____     24.   The following symptom(s) in the patient’s history should raise the clinician’s suspicion of colon cancer:

A. Alternating constipation and diarrhea
B. Narrowed caliber of stool
C. Hematochezia
D. All of the above

 

 

____     25.   A patient presents to the emergency department with nausea and severe, colicky back pain that radiates into the groin. When asked to locate the pain, he points to the right costovertebral angle region. His physical examination is unremarkable. Which of the following lab tests is most important for the diagnosis?

A. Urinalysis
B. Serum electrolyte levels
C. Digital rectal exam
D. Lumbar x-ray

 

 

____     26.   Your 34-year-old female patient complains of a feeling of “heaviness” in the right lower quadrant, achiness, and bloating. On pelvic examination, there is a palpable mass in the right lower quadrant. Urine and serum pregnancy tests are negative. The diagnostic tool that would be most helpful is:

A. Digital rectal exam
B. Transvaginal ultrasound
C. Pap smear
D. Urinalysis

 

 

____     27.   Your 54-year-old male patient complains of a painless “lump” in his lower left abdomen that comes and goes for the past couple of weeks. When examining the abdomen, you should have the patient:

A. Lie flat and take a deep breath
B. Stand and bear down against your hand
C. Prepare for a digital rectal examination
D. Lie in a left lateral recumbent position

 

 

____     28.   A nurse practitioner reports that your patient’s abdominal x-ray demonstrates multiple air-fluid levels in the bowel. This is a diagnostic finding found in:

A. Appendicitis
B. Cholecystitis
C. Bowel obstruction
D. Diverticulitis

 

 

____     29.   A 76-year-old patient presents to the emergency department with severe left lower quadrant abdominal pain, diarrhea, and fever. On physical examination, you note the patient has a positive heel strike, and left lower abdominal rebound tenderness. These are typical signs and symptoms of which of the following conditions?

A. Diverticulitis
B. Salpingitis
C. Inflammatory bowel disease
D. Irritable bowel syndrome

 

 

____     30.   Which of the following conditions is the most common cause of nausea, vomiting, and diarrhea?

A. Viral gastroenteritis
B. Staphylococcal food poisoning
C. Acute hepatitis A
D. E.coli gastroenteritis

 

 

____     31.   A patient presents to the emergency department with complaints of vomiting and abdominal pain. You note that the emesis contains bile. On physical examination, there is diffuse tenderness, abdominal distension, and rushing, high-pitched bowel sounds. Which of the following diagnoses would be most likely?

A. Gastric outlet obstruction
B. Small bowel obstruction
C. Distal intestinal blockage
D. Colonic obstruction

 

 

____     32.   Your 5-year-old female patient presents to the emergency department with sore throat, vomiting, ear ache, 103 degree fever, photophobia, and nuchal rigidity. She has an episode of projectile vomiting while you are examining her. The clinician should recognize that the following should be done:

A. Abdominal x-ray
B. Fundoscopic examination
C. Lumbar puncture
D. Analysis of vomitus

 

 

____     33.   A 9-year-old boy accompanied by his mother reports that since he came home from summer camp, he has had fever, nausea, vomiting, severe abdominal cramps and watery stools that contain blood and mucus. The clinician should recognize the importance of:

A. Stool for ova and parasites
B. Abdominal x-ray
C. Stool for clostridium
D. Fecal occult blood test

 

 

____     34.   A 56-year-old male complains of anorexia, changes in bowel habits, extreme fatigue, and unintentional weight loss. At times he is constipated and other times he has episodes of diarrhea. His physical examination is unremarkable. It is important for the clinician to recognize the importance of:

A. CBC with differential
B. Stool culture and sensitivity
C. Abdominal x-ray
D. Colonoscopy

 

 

____     35.   A 20-year-old engineering student complains of episodes of abdominal discomfort, bloating, and episodes of diarrhea. The symptoms usually occur after eating, and pain is frequently relieved with bowel movement. She is on a “celiac diet” and the episodic symptoms persist. Physical examination and diagnostic tests are negative. Colonoscopy is negative for any abnormalities. This is a history and physical consistent with:

A. Inflammatory bowel disease
B. Irritable bowel syndrome
C. Laxative abuse
D. Norovirus gastroenteritis

 

 

____     36.   A 78-year-old female patient is suffering from heart failure, GERD, diabetes, and depression. She presents with complaints of frequent episodes of constipation. Her last bowel movement was 1 week ago. Upon examination, you palpate a hard mass is the left lower quadrant of the abdomen. You review her list of medications. Which of the following of her medications cause constipation?

A. Digitalis (Lanoxin)
B. Amlodipine (Norvasc)
C. Sertraline (Zoloft)
D. Metformin (Glucophage)

 

 

____     37.   You are examining a 55-year-old female patient with a history of alcohol abuse. She complains of anorexia, nausea, pruritus, and weight loss over the last month. On physical examination, you note yellow hue of the skin and sclera. Which of the following physical examination techniques is most important?

A. Scratch test
B. Heel strike
C. Digital rectal examination
D. Pelvic examination

 

 

____     38.   You observe Charcot’s triad of sign and symptoms in a patient under your care. This is commonly seen in which of the following disorders?

A. Cirrhosis
B. Pancreatitis
C. Cholangitis
D. Portal hypertension

 

 

____     39.   A 59-year-old patient with history of alcohol abuse is admitted for hematemesis. On physical examination, you note ascites and caput medusa. A likely cause for the hematemesis is:

A. Peptic ulcer disease
B. Barrett’s esophagus
C. Pancreatitis
D. Esophageal varices

 

 

____     40.   A 16-year-old female with anorexia and bulimia is admitted for hematemesis. She admits to inducing vomiting often. On physical examination, you note pallor, BMI less than 15, and hypotension. A likely reason for hematemesis is:

A. Mallory-Weiss tear
B. Cirrhosis
C. Peptic ulcer disease
D. Esophageal varies

 

 

____     41.   An 82-year-old female presents to the emergency department with epigastric pain and weakness. She admits to having dark, tarry stools for the last few days. She reports a long history of pain due to osteoarthritis. She self-medicates daily with ibuprofen, naprosyn, and aspirin for joint pain. On physical examination, she has orthostatic hypotension and pallor. Fecal occult blood test is positive. A likely etiology of the patient’s problem is:

A. Mallory-Weiss tear
B. Esophageal varices
C. Gastric ulcer
D. Colon cancer

 

 

____     42.   A 48-year-old male presents to the clinic with complaints of anorexia, nausea, weakness, and unintentional weight loss over the last few weeks. On physical examination, the patient has jaundice of the skin as well as sclera and a palpable mass in the epigastric region. In addition to CBC and bilirubin levels, all of the following tests would be helpful except:

A. Liver enzymes
B. Amylase
C. Lipase
D. Uric acid

 

 

____     43.   Your 66-year-old male patient complains of weakness, fatigue, chronic constipation for the last month, and dark stools. On CBC, his results show iron deficiency anemia. Colon cancer is diagnosed. Which of the following laboratory tests is used to follow progress of colon cancer?

A. Alpha fetoprotein (AFP)
B. Carcinogenic embryonic antigen (CEA)
C. Carcinoma antigen 125 (CA-125)
D. Beta-human chorionic gonadotropin (beta HCG)

 

 

____     44.   Your patient is a 33-year-old female gave birth last week. She complains of constipation, rectal pain, and itching. She reports bright red blood on the toilet tissue. The clinician should recognize the need for:

A. Digital rectal exam
B. CEA blood test
C. Colonoscopy
D. Fecal occult blood test

 

Chapter 10. Abdomen

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:   C

The abdominal examination begins with inspection, followed by auscultation, percussion, and palpation. Light palpation should precede deep palpation. Auscultating before percussion or palpation allows the examiner to listen to the abdominal sounds undisturbed. Moreover, if pain is present, it is best to leave palpation until last and to gather other data before possibly causing the patient discomfort.

 

PTS:    1

 

  1. ANS:   D

Perform auscultation before palpation so as to hear unaltered bowel sounds. Listen for bruits over the aorta and the iliac, renal, and femoral arteries.

 

PTS:    1

 

  1. ANS:   A

The purpose of liver percussion is to measure the liver size. The technique used to percuss the liver is as follows:

  1. Starting in the midclavicular line at about the 3rd intercostal space, lightly percuss and move down.
  2. Percuss inferiorly until dullness denotes the liver’s upper border (usually at fifth intercostal space in MCL).
  3. Resume percussion from below the umbilicus on the midclavicular line in an area of tympany.
  4. Percuss superiorly until dullness indicates the liver’s inferior border.
  5. Measure span in centimeters. Normal liver span: clinically estimated at midclavicular line: 6-12 cm and midsternal line: 4-8 cm.

 

PTS:    1

 

  1. ANS:   D

A digital rectal examination is included in the abdominal examination. Note skin changes or lesions in the perianal region or the presence of external hemorrhoids. Insert the gloved index finger into the anus with the patient either leaning over or side-lying on the examination table, and note any internal hemorrhoids or fissures. Check the stool for occult blood. For males, the rectal examination is necessary for direct examination of the prostate. Ureteral stenosis is detected by angiographt.

 

PTS:    1

 

  1. ANS:   B

Rebound tenderness is tested by slowly pressing over the abdomen with your fingertips, holding the position until pain subsides or the patient adjusts to the discomfort, and then quickly removing the pressure. Rebound pain, a sign of peritoneal inflammation, is present if the patient experiences a sharp discomfort over the inflamed site when pressure is released.

 

PTS:    1

 

  1. ANS:   C

Appendicitis is suggested by a positive Rovsing’s sign. This sign is positive when there is referred rebound pain in the right lower quadrant when the examiner presses deeply in the left lower quadrant and then quickly releases the pressure.

 

PTS:    1

 

  1. ANS:   D

Ask the patient to stand with straight legs and to raise up on toes. Then ask the patient to relax, allowing the heel to strike the floor, thus jarring the body. A positive heel strike is indicative of appendicitis and peritoneal irritation. Alternatively, strike the plantar surface of the heel with your fist while the patient rests supine on the examination table.

 

PTS:    1

 

  1. ANS:   A

To examine the patient for appendicitis, the clinician can test the patient for psoas sign. This is done in the following manner: Place a hand on the patient’s thigh just above the knee and ask the patient to raise the thigh against your hand. This contracts the psoas muscle and produces pain in patients with an inflamed appendix.

 

PTS:    1

 

  1. ANS:   D

Murphy’s Sign is elicited by deeply palpating the right upper quadrant of the abdomen. Pain is present on deep inspiration when an inflamed gallbladder is palpated by pressing the fingers under the rib cage. Murphy’s sign is positive in cholecystitis.

 

PTS:    1

 

  1. ANS:   C

A positive obturator sign indicates appendicitis. Pain is elicited by inward rotation of the right hip with the knee bent so that the obturator internus muscle is stretched.

 

PTS:    1

 

  1. ANS:   B

Hepatojugular reflux is elicited by applying firm, sustained hand pressure to the abdomen in the midepigastric region while the patient breathes regularly. Observe the neck for elevation of the jugular venous pressure (JVP) with pressure of the hand and a sudden drop of the JVP when the hand pressure is released. Hepatojugular reflux is exaggerated in right heart failure.

 

PTS:    1

 

  1. ANS:   C

To assess the patient for ascites, test for shifting of the peritoneal fluid to the dependent side by rolling the patient side to side and percussing for dullness on the dependent side of the abdomen.

 

PTS:    1

 

  1. ANS:   B

In cholecystitis, acute colicky pain is localized in the RUQ and is often accompanied by nausea and vomiting. Murphy’s sign is frequently present. Fever is low grade, and the increase in neutrophilic leukocytes in the blood is slight. Acute cholecystitis improves in 2 to 3 days and resolves within a week; however, recurrences are common. If acute cholecystitis is accompanied by jaundice and cholestasis (arrest of bile excretion), suspect common duct obstruction.

 

PTS:    1

 

  1. ANS:   D

Biliary tract disease and alcoholism account for 80% or more of the pancreatitis admissions. Other causes include hyperlipidemia, drugs, toxins, infection, structural abnormalities, surgery, vascular disease, trauma, hyperparathyroidism and hypercalcemia, renal transplantation, and hereditary pancreatitis. The most common cause of pancreatitis is alcohol abuse.

 

PTS:    1

 

  1. ANS:   C

The Ranson rule uses a score determined by MRI results, with an index possible range of 0 to 10. A categorization of patients indicates the risk of both mortality and complication from pancreatitis. Patients at the low end of the index (1–3) are predicted to have a low risk of mortality (3%) and complications (8%), whereas patients scoring at the high end (7–10) of the index are predicted to have a higher incidence of mortality (17%) and/or complications (92%).

 

PTS:    1

 

  1. ANS:   A

LUQ pain can be associated with stomach or spleen disorders; however, it is often associated with causes that are outside the abdomen. Hematopoietic malignancies, such as lymphomas and leukemias, and other hematologic disorders, such as thrombocytopenia, polycythemia, myelofibrosis, and hemolyticanemia, often cause enlargement of the spleen, leading to LUQ pain. In addition to questions about the specific characteristics of the pain, it is important to ask the patient about fever, unusual bleeding or bruising, recent diagnosis of mononucleosis, fatigue, malaise, lymphadenopathy, cough, arthralgias, anorexia, weight loss, jaundice, high blood pressure, and headache.

 

PTS:    1

 

  1. ANS:   B

Hypersplenism is secondary to other primary disorders, most commonly cytopenic hematologic disorders, such as lymphoma, leukemia, thrombocytopenia, polycythemia, myelofibrosis, and haemolytic anemias. With the sore throat and cervical lymphadenopathy, infection due to Epstein-Barr virus is common in adolescents. Infectious mononucleosis is an important disorder to consider. Splenomegaly often occurs in infectious mononucleosis.

 

PTS:    1

 

  1. ANS:   C

A positive hemoccult on rectal examination may indicate an upper GI bleed or malignancy. Malignancy should also be suspected if there is weight loss and/or a palpable abdominal mass.

 

PTS:    1

 

  1. ANS:   A

GERD is the most common organic cause of heartburn. GERD is caused by decreased lower esophageal sphincter (LES) tone. LES control can be decreased by several medications (e.g., theophylline, dopamine, diazepam, calcium-channel blockers), foods and/or beverages (caffeine, alcohol, chocolate, fatty foods), and tobacco use. When LES tone is lower than normal, secretions are allowed to reflux into the esophagus, causing discomfort.

 

PTS:    1

 

  1. ANS:   D

A female with abdominal pain can have a GI or GU disorder or gynecologic problem. It is imperative to ask about the last menstrual period (LMP) and about birth control methods in order to rule out ectopic pregnancy. A history of miscarriages and/or sexually transmitted diseases (STDs) can give more clues for the risk of ectopic pregnancy. Safe sex practices and the number of sexual partners can alert the practitioner to the risk for pelvic inflammatory disease. No complaint of lower abdominal pain in a female should be evaluated without performing a pelvic examination.

 

PTS:    1

 

  1. ANS:   B

The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. There is tenderness on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distention with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening.

 

PTS:    1

 

  1. ANS:   A

The most obvious sign of ectopic pregnancy is amenorrhea followed by spotting and sudden onset of severe lower quadrant pain. A stat pregnancy test should be performed. The diagnosis of ectopic pregnancy can be made with urine human chorionic gonadotropin (hCG) or stat serum hCG, pelvic ultrasound, and, if necessary, culdocentesis to detect blood in the cul-de-sac. There is tenderness on pelvic examination, and a pelvic mass may be palpated. Blood is present in the cul-de-sac. Shock and hemorrhage occur if the pregnancy ruptures. Abdominal distension with peritoneal signs will ensue. Immediate laparoscopy or laparotomy is indicated because this condition is life threatening.

 

PTS:    1

 

  1. ANS:   C

Colorectal cancer is the second leading cause of death from malignancies in the United States. Over half are located in the rectosigmoid region and are typically adenocarcinomas. Risk factors include a history of polyps, positive family history of colon cancer or familial polyposis, ulcerative colitis, granulomatous colitis, and a diet low in fiber and high in animal protein, fat, and refined carbohydrates.

 

PTS:    1

 

  1. ANS:   D

Colon cancer may be present for several years before symptoms appear. Complaints include fatigue, weakness, weight loss, alternating constipation and diarrhea, a change in the caliber of stool, tenesmus, urgency, and hematochezia. Physical examination is usually normal except in advanced disease, when the tumor can be palpated or hepatomegaly is present, owing to metastatic disease.

 

PTS:    1

 

  1. ANS:   A

Urinary calculi can occur anywhere in the urinary tract; therefore, pain can originate in the flank or kidney area and radiate into the RLQ or LLQ and then to the suprapubic area as the stone attempts to move down the tract. The pain is severe, acute, and colicky and may be accompanied by nausea and vomiting. If the stone becomes lodged at the ureterovesical junction, the patient will complain of urgency and frequency. Blood will be present in the urine.

 

PTS:    1

 

  1. ANS:   B

Ovarian masses are often asymptomatic, but symptoms may include pressure-type pain, heaviness, aching, and bloating. Masses are typically detected on pelvic examination. In advanced malignancies, ascites is often present. An elevated cancer antigen 125 (CA-125) result indicates the likelihood that the mass is malignant. A transvaginal pelvic ultrasound has a higher diagnostic sensitivity than transabdominal ultrasound. If diagnosis is unclear, CT, MRI, or PET scan can be performed. A laparoscopy or exploratory laparotomy is necessary for staging, tumor debulking, and resection.

 

PTS:    1

 

  1. ANS:   B

In the majority of hernia cases, a history of heavy physical labor or heavy lifting can be elicited. Right or left lower quadrant pain that may radiate into the groin or testicle is typical. The pain is usually dull or aching unless strangulated, in which case the pain is more severe. The pain increases with straining, lifting, or movement of the lower extremities. Physical examination includes palpating the femoral area and inguinal ring for bulging or tenderness. Ask the patient to bear down against your hand.

 

PTS:    1

 

  1. ANS:   C

The most common causes of mechanical obstruction are adhesions, almost exclusively in patients with previous abdominal surgery, hernias, tumors, volvulus, inflammatory bowel disease (Crohn’s disease, colitis), Hirschsprung’s disease, fecal impaction, and radiation enteritis. Initially, the patient complains of a cramping periumbilical pain that eventually becomes constant. Physical examination reveals mild, diffuse tenderness without peritoneal signs, and possibly visible peristaltic waves. In early obstruction, tinkles, rushes, and borborygmi can be heard. In late obstruction, bowel sounds may be absent. The diagnosis can be made with flat and upright abdominal films looking for bowel distension and the presence of multiple air-fluid levels. CT or MRI may be necessary for confirmation.

 

PTS:    1

 

  1. ANS:   A

Diverticular disease is prevalent in patients over 60 years of age. Since the sigmoid colon has the smallest diameter of any portion of the colon, it is the most common site for the development of diverticula. Although the pain can be generalized, it is typically localized to the left lower abdomen and is accompanied by tenderness, fever, and leukocytosis. Other symptoms can include constipation or loose stools, nausea, vomiting, and positive stool occult blood. With diverticulitis, there is an increased risk of perforation, which presents with a more dramatic clinical picture as a result of peritonitis. Look for signs of peritonitis, such as a positive heel strike test and/or rebound tenderness.

 

PTS:    1

 

  1. ANS:   A

Viral gastroenteritis is the most common cause of nausea, vomiting, and diarrhea. At least 50% of cases of gastroenteritis as foodborne illness are due to norovirus. Another 20% of cases, and the majority of severe cases in children, are due to rotavirus. Other significant viral agents include adenovirus and astrovirus.

 

PTS:    1

 

  1. ANS:   B

The contents of the vomitus commonly vary according to the level of obstruction. Gastric outlet obstruction is associated with emesis containing undigested food. Proximal small intestinal blockage is likely to be bile-stained. Distal intestinal blockage is more likely to contain fecal matter. The degree of cramping and pain is often related to the proximity of the obstruction, so that obstructions of the lower intestines may have less severe cramping, vomiting, and/or pain. Bowel sounds often are high pitched and metallic sounding but may later become absent. Tenderness may be localized or diffuse. Distention as well as a succussion splash may be present.

 

PTS:    1

 

  1. ANS:   C

The range of neurologic disorders that result in nausea and/or vomiting is broad. Included are meningitis, increased intracranial pressure (ICP), migraines, a space-occupying lesion, and Ménière’s disorder. Central nervous system-related vomiting is often projectile and may not be preceded by nausea. Papilledema may accompany increased ICP. Neurological deficits may be evident with increased ICP, space-occupying lesions, and meningitis. Nuchal rigidity is a classic finding for meningitis.

 

PTS:    1

 

  1. ANS:   A

Parasites causing diarrhea usually enter the body through the mouth. They are swallowed and can remain in the intestine or burrow through the intestinal wall and invade other organs. Certain parasites, most commonly Giardia lamblia, transmitted by fecally contaminated water or food, can cause diarrhea, bloating, flatulence, cramps, nausea, anorexia, weight loss, greasy stools because of its interference with fat absorption, and occasionally fever. Symptoms usually occur about 2 weeks after exposure and can last 2 to 3 months. Often, the symptoms are vague and intermittent, which makes diagnosis more difficult. Serial stool samples for O&P should be ordered because a single sample may not reveal the offending parasite.

 

PTS:    1

 

  1. ANS:   D

The symptoms and severity of the diarrhea vary according to the underlying cause. The symptoms of carcinomas are generally insidious. The diarrhea is mild and intermittent. Often malignancies are found on routine hemoccults, sigmoidoscopy, or colonoscopy. There should be a high index of suspicion with unexplained weight loss or new-onset iron-deficiency anemia in a patient over 40 years old.

 

PTS:    1

 

  1. ANS:   B

Irritable bowel syndrome (IBS) is a functional bowel disorder characterized by mild to severe abdominal pain, discomfort, bloating, and alteration of bowel habits. The exact cause is unknown. In some cases, the symptoms are relieved by bowel movements. Diarrhea or constipation may predominate, or they may be mixed (classified as IBS-D, IBS-C, or IBS-M, respectively). IBS may begin after an infection (postinfectious, IBS-PI) or a stressful life event. IBS is a motility disorder involving the upper and lower GI tracts that causes intermittent nausea, abdominal pain and distention, flatulence, pain relieved by defecation, diarrhea, and/or constipation. Symptoms usually occur in the waking hours and may be worsened or triggered by meals. It is three times more prevalent in women, accounts for more than half of all GI referrals, and is highly correlated with emotional factors, particularly anxiety and stress.

 

PTS:    1

 

  1. ANS:   B

Medications that frequently cause constipation include:

– Analgesics/narcotics

– Antacids containing aluminum

– Anticonvulsants

– Antidepressants

– Antihypertensives (calcium-channel blockers, beta blockers)

– Antiparkinsonism agents

– Antispasmodics

– Calcium supplements

– Diuretics

– Iron supplements

– Sedatives/tranquilizers

 

PTS:    1

 

  1. ANS:   A

Cirrhosis develops with the replacement of normal liver tissue by regenerative, fibrotic nodules and may occur in the late phase of a variety of disorders that damage the liver, such as alcohol toxicity. A patient may present with jaundice and describe an associated, progressive pattern of pruritus, weakness, anorexia, nausea, and weight loss. Determine the size and consistency of the liver as well as any tenderness. The scratch test is a method used to ascertain the location and size of a patient’s liver during a physical assessment. The scratch test uses auscultation to detect the differences in sound transmission through the abdominal cavity over solid and hollow organs and spaces. After placing a stethoscope over the approximate location of a patient’s liver, the examiner will then scratch the skin of the patient’s abdomen lightly, moving laterally along the liver border. When the liver is encountered, the scratching sound heard in the stethoscope will increase significantly. In this manner, the size and shape of a patient’s liver can be ascertained.

 

PTS:    1

 

  1. ANS:   C

Occlusion of the common bile duct may occur with disorders of the gallbladder and/or bile duct, such as cholecystitis, cholelithiasis, and cholangitis. All three conditions are generally accompanied by RUQ discomfort, anorexia, and nausea. Charcot’s triad, which includes jaundice, RUQ pain, and fever/chills, is common to problems resulting in obstructions of the bile duct.

 

PTS:    1

 

  1. ANS:   D

Patients with portal hypertension may develop GI bleeding from varices of the esophagus, stomach, intestines, or other sites. Portal hypertension is most commonly associated with cirrhosis, usually caused by alcohol abuse or hepatitis.  Check for signs of liver disease, including jaundice, cirrhosis, telangiectasia, hepatomegaly, and RUQ tenderness. Ascites occurs due to venous congestion. Caput medusa is the distension of paraumbilical veins due to portal hypertension.

 

PTS:    1

 

  1. ANS:   A

Upper GI hemorrhage may result from a tear at the gastroesophageal junction, known as a Mallory-Weiss tear. A patient may develop more than one tear. These tears are most common in alcoholic or bulimic patients following repeated episodes of vomiting or severe retching. If a laceration/tear of the mucosa causes GI bleeding, the patient may demonstrate alterations in hemodynamic status.

 

PTS:    1

 

  1. ANS:   C

Bleeding occurs after an area of gastric mucosal injury has ulcerated. Explore symptoms of epigastric and/or periumbilical discomfort. Identify potential causes of gastric mucosal injury—the most common being NSAID use and stress. Many elderly individuals self-medicate with over-the-counter aspirin preparations and various NSAIDs. Commonly, they use too many medications that have side effects of gastric irritation.

 

PTS:    1

 

  1. ANS:   D

Primary or metastatic cancers of the liver and/or pancreas can cause obstructive hyperbilirubinemia and jaundice. Jaundice may be the initial sign of a malignancy or may follow the development of other symptoms. Ask about associated symptoms, such as RUQ discomfort, nausea, fever, back pain, weight loss, fatigue/weakness, and pruritus. None of these symptoms are specific to malignancy; however, other causes of jaundice are less likely to be associated with weight loss. During the abdominal examination, carefully palpate the area of the liver and the remainder of the abdomen, checking for masses or unexpected findings. In addition to a CBC, liver functions, amylase, lipase, and bilirubin levels, abdominal CT and/or ultrasound should be ordered promptly.

 

PTS:    1

 

  1. ANS:   B

AFP can help diagnose and guide the treatment of liver cancer (hepatocellular carcinoma). CA-125 is the standard tumor marker used to follow women during or after treatment for epithelial ovarian cancer (the most common type of ovarian cancer) as well as fallopian tube cancer and primary peritoneal cancer. Serum beta HCG is a pregnancy marker. CEA is not used to diagnose or screen for colorectal cancer, but it’s the preferred tumor marker to help predict outlook in patients with colorectal cancer. The higher the CEA level at the time colorectal cancer is detected, the more likely it is that the cancer is advanced.

 

PTS:    1

 

  1. ANS:   A

The most common cause of lower GI bleeding is hemorrhoids. The bleeding associated with hemorrhoids is usually evident as red blood on the formed stool, in the toilet bowl, or on the toilet tissue following a bowel movement. Patients with hemorrhoids often complain of rectal discomfort as well as the contributing factors for hemorrhoid development, including constipation. Inspect the perianal rectal tissue. Anoscopy may be indicated. Perform a digital rectal examination to assess internal haemorrhoids.

 

PTS:    1

Chapter 20. Older Patients

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____       1.   Based on the 2010 Census of the United States, the fastest growing segment of the population is:

A. Adults aged 65 to 75
B. Adults aged 75 to 85
C. Adults aged 85 to 95
D. Adults aged 100+

 

 

____       2.   The order of the physical examination in the older patient should:

A. Begin with gait observation or transfer ability from wheelchair to exam table
B. Begin with activities that cause the least expenditure of energy
C. Be performed in a head-to-toe sequence
D. Be a focused physical examination limited to the patient symptoms

 

 

____       3.   A functional assessment is the most appropriate type of evaluation of well older patients. A basic component of the functional assessment is:

A. Activities of Daily Living (ADL) score
B. Instrumental Activities of Daily Living (IADL) score
C. 10-minute Screener for Geriatric Conditions
D. All of the above

 

 

____       4.   A preliminary, concise test to screen patients for dementia in primary care is the:

A. Mini-mental status exam (MMSE)
B. Mini-Cog Clock Drawing test
C. Geriatric Depression Scale
D. Physical Self-Maintenance Scale

 

 

____       5.   After a preliminary screen for dementia, a highly sensitive test that should be used to assess for cognitive impairment of the older patient is:

A. The Montreal Cognitive Assessment (MoCA)
B. Mini-mental status exam (MMSE)
C. Mini-Cog Clock Drawing test
D. Activities of Daily Living (ADL)

 

 

____       6.   The MMSE has been criticized because:

A. Patients who are being tested require education
B. It is not applicable for patients from varied cultures
C. It cannot differentiate between delirium, dementia, and depression in the older patient
D. All of the above

 

 

____       7.   The most common reason for functional decline in nursing home patients is:

A. Heart failure
B. Stroke
C. Urinary tract infection
D. Myocardial infarction

 

 

____       8.   One of the most common causes for cognitive impairment in older patients suffering from infection is:

A. Delirium
B. Depression
C. Dementia
D. Pseudodementia

 

 

____       9.   Which of the following is a preventable condition in sedentary hospitalized older adults?

A. Falls
B. Decubitus ulcer
C. Delirium
D. All of the above

 

 

____     10.   What are some tests of mobility to include in a physical examination of older adults?

A. Get up and go
B. Tinetti Evaluation
C. Fall toolkit
D. All of the above

 

 

____     11.   Prior to giving clearance for an older adult to take part in an exercise regimen, the ____ assessment tool should be used by the clinician.

A. Get up and go
B. Tinetti scale
C. PARmed-X
D. PAR-Q

 

 

____     12.   The rapid pace walk is a good screening test for driving ability of the elderly. The patient is timed to walk as swiftly as possible along a 10 foot path. A completion time of greater than____ indicates possible need for intervention.

A. 9 seconds
B. 8 seconds
C. 7 seconds
D. 6 seconds

 

 

____     13.   During examination of the eyes, dilation of the pupil is needed to check for:

A. Distance vision
B. Macular degeneration
C. Cataracts
D. Peripheral vision

 

 

____     14.   A get up and go test involves having the patient rise from a chair, walk 20 feet, turn and walk back to the examiner. This should be completed within____ seconds.

A. 10
B. 15
C. 20
D. 25

 

 

____     15.   The functional reach test is a good predictor of:

A. Susceptibility to fall
B. Complete range of motion
C. Dependence in ADLs
D. A & C

 

 

____     16.   Adults tend to lose 1 inch every ____ years after age 40.

A. 30
B. 25
C. 20
D. 15

 

 

____     17.   For measuring weight in patients in long-term care facilities:

A. Always use same scale
B. Record the patient’s clothing
C. Calculate the body mass index (BMI)
D. All the above

 

 

____     18.   A BMI of less than ____ is an indicator of high risk for malnutrition.

A. 21
B. 22
C. 23
D. 24

 

 

____     19.   A total weight of less than ____ pounds is an indicator for high risk for malnutrition.

A. 120
B. 115
C. 110
D. 100

 

 

____     20.   Useful laboratory measures that indicate protein–energy malnutrition in hospitalized elders include a serum albumin level below____.

A. 3.4 g/dl
B. 4.2 g/dl
C. 5.2 g/dl
D. 6.4 g/dl

 

 

____     21.   A useful laboratory measure that indicates protein-energy malnutrition in hospitalized elders include a total cholesterol below____.

A. 190 mg/dl
B. 180 mg/dl
C. 170 mg/dl
D. 160 mg/dl

 

 

____     22.   Obesity defined as a BMI greater than ____ is an independent risk factor for functional decline in the elderly patient.

A. 20
B. 24
C. 30
D. 35

 

 

____     23.   The best indicator of fluid status in the elderly is____.

A. Patient thirst
B. Patient weight
C. BUN/creatinine ratio
D. Serum creatinine

 

 

____     24.   Which of the following is regarded as a “quality of care” indicator?

A. Frequent episodes of dehydration
B. Pattern of weight loss
C. Chronic constipation
D. Repeat urinary tract infections

 

 

____     25.   Which of the following statements is true?

A. Women have a higher prevalence of functional decline than men at the upper end of BMI
B. Men have a higher prevalence of functional decline than women at the upper end of BMI
C. To be sure the elderly patient’s fluid needs are met, the clinician should rely on the patient’s thirst
D. The “get up and go” test is a more accurate assessment of gait and balance than the Tinetti Mobility Scale.

 

Chapter 20. Older Patients

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:   D

According to 2010 United States census data, the number of older adults, aged 65 and over, increased by 15.3% from 2000 to a total of 40.4 million (13.1% of the total United States population); it is estimated that number will increase to about 55 million by 2020 (Administration on Aging, 2011). The fastest growing group among older adults since the 1990 census are those over 100 years of age, increasing by 53% to a total of 53,364 in 2010 (National Center for Health Statistics, 2013). Most of these centenarians are considered to be among the most vulnerable to frailty and disability, which, coupled with the likelihood that they will live alone and, therefore, require support services, such as nursing home care, has caused dire predictions about the failure of the Medicare and Medicaid systems.

 

PTS:    1

 

  1. ANS:   B

The approach to the physical examination of older adults will not differ greatly from standard examination techniques presented in this text. Some tests of functional ability are not routinely considered in the usual examination of the adult; those are presented in the various sections that follow. With older adults who are debilitated, it is important to focus the examination and reduce extraneous activities and distractions. Whenever possible, begin the examination with maneuvers that can be accomplished with the patient in his or her current position. For example, when the patient arrives to the examination seated in a wheelchair, check vital signs, heart rate, extremities, or anything else that can be done in the seated position first. If a patient’s ability to transfer from the wheelchair is in question, observe the transfer before the patient becomes fatigued. The exertion of getting on the examination table could fatigue an individual enough to preclude optimal performance. Likewise, perform all supine or standing examinations together to preserve the patient’s stamina. A reordering of the sequence of the examination should be done in a logical and thoughtful manner.

 

PTS:    1

 

  1. ANS:   D

For the well elderly, the 10-Minute Screener for Geriatric Conditions is a useful tool for general practice (Bluestein & Rutledge 2006). This brief screening tool (Table 20.2) addresses vision, hearing, leg mobility, urinary incontinence, nutrition and weight loss, memory, depression, and physical disability. Using a combination of subjective and objective measures, the 10-Minute Screener covers all the basic ADL and IADL functions in a manner that fits well within the outpatient examination. A positive screen requires further evaluation, in some cases by a specialist or a geriatric specialist.

 

PTS:    1

 

  1. ANS:   B

See Box 20.2, Box 20.3, Box 20.4 and Table 20.2, Table 20.3.

 

PTS:    1

 

  1. ANS:   A

One instrument that holds promise for rapid screening in primary care is the Mini-Cog (Box 20.4); it takes 2 to 4 minutes to administer, has good sensitivity (76% to 99%) and specificity (89% to 96%), and has been validated in primary care (Harvan & Cotter 2006). A positive screen on the Mini-Cog requires a more thorough evaluation. The Montreal Cognitive Assessment (MoCA) is the most sensitive instrument for detecting mild cognitive impairment; the MoCA website contains detailed instructions and normative data for the test in 35 languages (www.mocatest.org).

 

PTS:    1

 

  1. ANS:   D

The most commonly used and widely tested instrument (USPSTF 2003) for the next step in the evaluation of cognitive function, which measures more than just short- and long-term memory, is the Mini-Mental State Examination (MMSE). Domains measured by the MMSE include orientation to time and place, registration, attention and calculation, recall, naming, repetition, comprehension, reading, writing, and drawing. Testing with the MMSE takes approximately 10 minutes, and it must be administered in a standard manner to obtain valid results. The total possible score is 30 points; however, scores are highly correlated with age and educational level of the individual (Ashla 2000; Harvan & Cotter 2006). Scores on the MMSE will not differentiate between delirium and dementia, although both conditions will cause scores below the cutoff of 24 (Francis, 2000). Comprehensive information on the development, reliability and validity testing, and scoring of the MMSE can be found online (www4.parinc.com). The MMSE is available for purchase only to qualified health-care professionals through Psychological Assessment Resources. A description of the qualifications for purchase can be found at www4.parinc.com.

 

PTS:    1

 

  1. ANS:   C

Clinical practice guidelines suggest that in 77% of episodes of functional decline in long-term care residents, infection is the cause, and the most frequent site of such infection is the urinary tract (55%).

 

PTS:    1

 

  1. ANS:   A

Delirium is a reversible condition frequently caused by infection (Table 20.4). After treatment of infection, delirium is usually resolved.

 

PTS:    1

 

  1. ANS:   A

Many of the geriatric syndromes are adverse events that occur as a result of immobility and hospitalization or inappropriate prescribing of medications; such syndromes require systems interventions to improve or change outcomes. Among these syndromes are four—falls, delirium, pressure ulcers, and underfeeding—that have been labeled as “medical errors” because they are largely preventable in hospitalized elders (Tsilimingras, Rosen, & Berlowitz 2003). It is important that nurse practitioners have a basic understanding of the risk factors, causes, and clinical presentations of geriatric syndromes and routinely assess for factors that may be amenable to intervention beyond the medical issues. Prevention is particularly important in managing geriatric syndromes both in the hospitalized and in the community-residing elder.

 

PTS:    1

 

  1. ANS:   D

The get-up-and-go test is a simple screening measure that takes only minutes and can be conducted by trained staff. Instruct the patient to stand up from a seated position without using his or her arms or the chair arms for support, walk a few feet away, turn around and return to the chair, and sit down again without using any support. If the examiner observes any instability or difficulty with this test, further evaluation of gait and balance is required. Using the example of falls again, a home safety evaluation that includes questions about lighting, clutter on floors, footwear, bathroom configuration, stairways, sidewalks, and the availability of help in the case of a fall can focus attention on areas where safety can be improved to prevent falls. A useful tool that can be completed by patients or their families is available online in the Falls Toolkit (www.gericareonline.net/tools/eng/falls) from the Practicing Physicians Education in Geriatrics (2006). In the case of patients who have fallen frequently, a home visit by a nurse or physical therapist is very helpful to determine what risk factors are modifiable.

 

PTS:    1

 

  1. ANS:   C

Older adults are increasingly turning to exercise for socialization and fitness, and this trend should be supported. The question always arises: How much screening and assessment should be conducted prior to initiating an exercise program? The Canadian Society for Exercise Physiology has developed a useful evidence-based, seven-question screening tool, the Physical Activity Readiness Questionnaire (PAR-Q) for screening adults up to age 69 (2002). The recommendation for those over age 69 who are not accustomed to being active is to consult with a health-care provider prior to initiating a formal exercise program. The questions on the PAR-Q require a yes or no response; any response of yes requires further screening by a health-care provider. There is a companion form, the PARmed-X, for the clinician to complete prior to the individual beginning a formal exercise program. The PARmed-X includes a clearance as well as suggestions for special prescriptions for conditions such as chronic obstructive pulmonary disease. There are relatively few absolute contraindications to exercise listed on the PARmed-X; they include acute infectious processes, dissecting aortic aneurysm, severe aortic stenosis, active or recent myocarditis, acute myocardial infarction or heart failure, and acute thrombotic or embolic processes. Once any acute illness is resolved, the adult should be rescreened and allowed to exercise to tolerance.

 

PTS:    1

 

  1. ANS:   A

The rapid pace walk is specifically suggested (AMA, 2010) as a good predictor of driving safety. The client is timed walking as swiftly as possible along a 10-foot path marked on the floor both away from and toward the examiner. A cane can be used, but this should be noted on the chart. A completion time of greater than 9 seconds indicates a possible need for intervention.

 

PTS:    1

 

  1. ANS:   B

An examination of the eyes should always include measuring ocular pressure to rule out glaucoma, which is a serious cause of blindness and is more common with aging; screening for close and distance vision, particularly when there are questions related to driving or medication-taking ability; dilating the pupil to examine the retina for macular degeneration, a common cause of blindness in the elderly; and screening for cataracts, also increasingly common with age. Referral to an optometrist or an ophthalmologist is ideal and may be covered by Medicare and other insurance, depending on the diagnosis.

 

PTS:    1

 

  1. ANS:   B

The timed get-up-and-go test should be administered to all clients who have experienced a fall or who report difficulty with strenuous activities, such as fast walking, heavy housework, shopping, or climbing stairs. It is easy to perform and takes very little additional time during the examination. Place a chair in an unobstructed location and instruct client to rise from the seated position, walk 20 feet, turn, walk back to the chair, and sit down. Time this activity with a stopwatch. In populations that cannot complete the task in 15 seconds or less, research has shown a strong correlation (0.6–0.8) with other measures of gait and balance (Gerety 2000).

 

PTS:    1

 

  1. ANS:   D

The functional reach test is another useful test for upper extremity function that correlates well with an increased risk for falls and dependence (Behrman et al. 2002). Give the client the following instructions: Stand with your feet hip-width apart and your right (dominant) side next to, but not touching, a wall. Extend your right arm (or whichever is closest to the wall) parallel to the floor at shoulder height with your fingers extended. Now reach forward as far as you can, bending at the waist, but do not lift your heels off the floor. The examiner measures the distance in centimeters from the back of the shoulder to the tip of the middle finger in the “normal reach” position and again in the “forward reach” position. Differences greater than 25 cm are a significant predictor of falls and increased dependence in ADLs and IADLs.

 

PTS:    1

 

  1. ANS:   C

One of the key factors in tracking malnutrition is measuring and recording clients’ heights and weights. Most adults overestimate their height and underestimate their weight on self-report; height is a particular problem because adults tend to lose 1 inch of height every 20 years after age 35 to 40. Measurement of standing height is difficult if there is any degree of kyphosis (underestimates the actual height).

 

PTS:    1

 

  1. ANS:   D

Obtain an accurate weight, and make sure the scale is calibrated. For residents of long-term care facilities, always use the same scale for the same patient and, if there is a change in scale, make sure to note that beside the weight. Document what the patient is wearing, and always weigh in that same state. Significant weight loss is a quality indicator measure, and a pattern of weight loss in any facility will trigger an investigation by state and federal regulatory agencies. Ask the patient’s usual body weight if possible. Calculate ideal body weight using the same formula as for any other population. Once you have obtained an accurate height and weight, calculate the body mass index (BMI).

 

PTS:    1

 

  1. ANS:   A

A BMI of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

 

PTS:    1

 

  1. ANS:   D

Once you have obtained an accurate height and weight, calculate the body mass index (BMI). For amputees, add the following percentages of the weight obtained on the scale prior to calculating the BMI: below knee 6%, at knee 9%, above knee 15%, arm 6.5%,  and arm below elbow 3.6%. The formula for calculating BMI is the same for the elderly as for any other population. A BMI of less than 21 or a total body weight of less than 100 pounds is an indicator of a high risk for protein-energy malnutrition.

 

PTS:    1

 

  1. ANS:   A

Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL.

 

PTS:    1

 

  1. ANS:   D

Useful laboratory measures that indicate protein-energy malnutrition or potentially poor outcomes in hospitalized elders include a serum albumin level below 3.4 g/dL and total cholesterol below 160 mg/dL.

 

PTS:    1

 

  1. ANS:   C

Although a lot of attention is devoted to undernutrition, obesity, defined as a BMI of greater than 30, or 20% greater than ideal body weight, is also an independent risk factor for functional decline in the elderly. Women have a higher prevalence of functional decline than men at the upper end of the BMI categories (three times greater risk at a BMI of greater than 35), independent of the usual factors, such as depression and polypharmacy (Jensen & Friedmann 2002).

 

PTS:    1

 

  1. ANS:   C

Dehydration is common in the elderly and has serious consequences. The average fluid intake for community-dwelling elderly persons is less than 1,000 mL per day. Thirst is not a reliable indicator of the need for fluids, and most elderly individuals need reminders to drink fluids. The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration.

 

PTS:    1

 

  1. ANS:   B

Obtain an accurate weight, and make sure the scale is calibrated. For residents of long-term care facilities, always use the same scale for the same patient and, if there is a change in scale, make sure to note that beside the weight. Document what the patient is wearing, and always weigh in that same state. Significant weight loss is a quality indicator measure, and a pattern of weight loss in any facility will trigger an investigation by state and federal regulatory agencies. Ask the patient’s usual body weight if possible. Calculate ideal body weight using the same formula as for any other population.

 

PTS:    1

 

  1. ANS:   A

Women have a higher prevalence of functional decline than men at the upper end of the BMI categories (three times greater risk at a BMI of greater than 35), independent of the usual factors, such as depression and polypharmacy (Jensen & Friedmann 2002).

Dehydration is common in the elderly and has serious consequences. The average fluid intake for community-dwelling elderly persons is less than 1,000 mL per day. Thirst is not a reliable indicator of the need for fluids, and most elderly individuals need reminders to drink fluids. The best method for monitoring hydration status is with the blood urea nitrogen/creatinine ratio; anything greater than 20:1 is highly suggestive of dehydration.

The Tinetti Performance-Oriented Mobility Assessment (POMA) scale is a more sensitive and specific test of gait, balance, and mobility (Box 20.9). The gait and mobility components of the POMA include opportunities to evaluate the initiation of gait, adequacy of step length and height, step and path symmetry and continuity, and ability to turn and pick up speed. Balance is tested by observing immediate standing balance; balance during tandem, one-leg, heel, and toe standing; and a nudge to the sternum or tug from behind. The POMA is sensitive and reproducible and can be used to measure improvement over time; thus, it is often used in clinical trials of exercise interventions.

 

PTS:    1

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