An 8-year-old with a history of known allergies has been experiencing a non-productive cough for the past 9 days. On day 9, the child’s temperature rose to 103.5 °F with an oxygen level of 92% on room air. Upon assessment, the child does not complain of ear or throat pain and has wheezes. The family nurse practitioner manages this patient by first:
- Ordering an immediate chest X-ray.
- Prescribing systemic antibiotics.
- Administering a bronchodilator via nebulizer.
- Referring the patient to a hospital for admission.
3. Administering a bronchodilator via nebulizer.
This is the first decision. The key word in this question is first, because the nurse practitioner may do all of these actions, but the immediate issue is to improve breathing. Prescribing antibiotics without a source is not recommended. The differential diagnosis is pneumonia, thus requiring an order for a chest X-ray. The referral for a hospital admission is not necessary at this time, with the goal being to keep a child out of the hospital as long as possible. The other key word is the age of a child, because the decision tree would be different if the patient was an 88-year-old.
An elderly patient’s family begs the nurse practitioner to start her on a medication to help with agitation, behavior problems, and sleep issues. The nurse practitioner counsels the family on the use of second-generation anti-psychotics. Which statement is true regarding these medications?
- "While they help with sedation, they have an increased cardiovascular risk."
- "These medications will help her sleep, but will lower her blood glucose levels."
- "While this will help with one problem, they place her at high risk for weight loss."
- "These medications will help her sleep, but we must monitor for suicidal ideations."
1. "While they help with sedation, they have an increased cardiovascular risk."
The key word is true. The learner needs to have knowledge about the medication prior to answering this question. This is an example of a question that if you do not know the answer, write it in your notebook to review the content. Also, to make an educated guess, elderly patients are at most risk for cardiovascular issues; therefore, this is a great concern for any elderly person. Do not read too much into the question and choose an answer based on thinking that perhaps the patient has diabetes mellitus or she is too thin. There is no indication that weight loss would be a bad issue for this patient. Be careful of adding your own subjectivity into the questions.
A 27-year-old male client with Hodgkin’s lymphoma in the abdominal and pelvic regions is about to start radiation therapy. Which information is the most important for the nurse practitioner to address?
- Sperm production being permanently disrupted.
- Constipation that will be continuous throughout therapy.
- Baldness resulting from the radiation therapy will be permanent.
- The treatment will increase the risk for prostate cancer later in life.
1. Sperm production being permanently disrupted.
Although all of these answers are true, the key word that is most important identifies addressing an immediate and life-changing issue. The patient’s age, which is noted in this question, clues you into the importance of it: having no future to produce a family, once undergoing radiation treatment, is extremely important. The nurse practitioner should address this immediately and suggest banking sperm for later use if desired, in order for the patient to have the future option of a family.
What is the most common source for the hepatitis A infection?
- Needle sharing
- Consuming raw shellfish
- Contaminated water supplies
- Intimate person-to-person contact
3. Contaminated water supplies
Although raw shellfish is a source of contracting hepatitis A, and the other two answers are other ways to transmit hepatitis B and C, the key words in this question are most common. This is an easy error to make by quickly answering the question after reading "raw shellfish" and not taking time to read the rest of the possible answers. The other strategy after choosing the answer is to reread the question if you are deciding between B and C and to pick up on the words most common. Another way to determine between B and C is to think about the entire world population and view this question in general terms, because eating raw shellfish does not happen in all cultures.
The nurse practitioner is evaluating a pregnant woman who was bitten by a deer tick and will be receiving treatment. Which medication would not be appropriate to prescribe for this patient?
- Cefuroxime axetil
Although all of these antibiotics may be used in a treatment plan for Lyme disease, the key words in this question are pregnant woman and not. The inclusion of the pregnancy is important and should always be used when making the critical decision. In reading carefully, the stem of the question should have had you identifying the word not. If you missed them the first time, reread the question to see what the key words are, since all of these answers are associated with treatment of the disorder.
An 18-year-old Chinese exchange student presents to student health for a well visit to follow up on his immunization record and the reading of his PPD result from 3 days ago. The PPD result is a 6-mm area of induration. What is the best initial intervention by the nurse practitioner?
- Order an immediate chest radiograph.
- Ask the student if he received BCG vaccine before.
- Prescribe isoniazid therapy immediately.
- Request the student to return in one month to repeat the PPD test.
2. Ask the student if he received BCG vaccine before.
The key word in this question is Chinese. The CDC recommends anyone with a positive PPD, regardless of receiving the BCG vaccine, to be treated the same due to the false-positives. Since this student is in a high-risk category, the FNP must know what is positive for this group. The 6-mm induration would be read as negative. To account for the induration, asking about a history of receiving the BCG vaccine is the next step. An Interferon-Gamma Release Assay (IGRA) could be ordered to evaluate if the student has been infected with M. tuberculosis. The patient’s ethnic background being Chinese was important; otherwise it would have been omitted in the question stem.
The family nurse practitioner is reviewing results with a patient who has received a positive rapid human immune deficient virus (HIV) test. What would be the most appropriate response by the provider?
- "You will need a Western blot test to confirm a positive diagnosis of HIV."
- "You will need to have your CD4 count tested immediately."
- "You have acquired human immune deficiency virus (HIV)."
- "Rapid tests have false positives."
1. "You will need a Western blot test to confirm a positive diagnosis of HIV."
Requiring a Western blot test is important for a confirmed positive HIV diagnosis. The key words are most appropriate. The patient should not be told they are positive for HIV without a confirming diagnosis, and they should not be given false hope if the first test was false positive. The patient does not need an immediate CD4 count; however, this will be part of the comprehensive workup later if the Western blot is positive for HIV. Therefore, the word immediate in answer B rules out this answer as being correct.
What is the common presentation between uncontrolled diabetes mellitus and human immune deficiency virus (HIV)?
- Vaginal candidiasis
- Gastric ulcer
2. Vaginal candidiasis
Vaginal candidiasis is a shared clinical presentation because of the high glucose levels with uncontrolled diabetes and being immunocompromised. When answering this question, ask yourself whether each one of these disorders is common (not atypical). That would rule out two of the answers. Retinopathy can occur with diabetes mellitus. Pneumonia can be associated with HIV/AIDS but not necessarily with DM, and gastric ulcers are not associated with either disease.
Governing guidelines require that all patients seen in a primary care setting be routinely screened for domestic violence. During the screening, privacy and confidentiality are essential components. Which of the following statements made by the family nurse practitioner may help create a nonthreatening environment when asking the adult client?
- "I am going to ask you some questions that may make you uncomfortable, but it is important that you answer them honestly."
- "I see that there is a strong history of drug and alcohol abuse in your personal history. This places you at risk for domestic violence. Do you want to discuss this further?"
- "I noticed that you were seen several times this past year by other providers in this office for complaints of abdominal pains and headaches. These can be indicators of domestic violence. Should I review these records and we can discuss this?"
- "Since domestic violence is so prevalent, and it may be difficult for patients to bring up, I have started routinely screening all my patients."
4. "Since domestic violence is so prevalent, and it may be difficult for patients to bring up, I have started routinely screening all my patients."
This is the most non-threatening answer that creates a non-judgmental atmosphere. The other answers are incorrect because the first answer would create an immediate defensive response since the NP is calling the client a liar before the question. B and C are incorrect because a judgment is being made about certain behaviors and placing blame on the client. When answering questions about statements that you should make to the client, repeat the answers out loud if you are unsure. Would anyone understand or accept that as a response? It is also helpful to think about a layperson who does not know anything medical and say those questions again. It is important not to think of yourself as the client because you already have a background in health care; therefore, your reactions would always be different than a regular person accessing health care.
The nurse practitioner evaluates a new patient who is an African American with hypertension who has been taking lisinopril (Prinivil). His current BP is 160/90. Which medication does the nurse practitioner prescribe to create a more effective treatment plan?
- Angiotensin-converting enzyme inhibitor
- Angiotensin II receptor blockers
- Calcium-channel blocker
3. Calcium-channel blocker
Calcium-channel blockers work well with the African American population. The key word in this situation involves addressing the cultural aspect of the client in determining a correct answer.