The most common cause of bacterial pharyngitis is:
- Group C Streptococcus.
- Group A Streptococcus.
4. Group A Streptococcus.
Streptococcus A is by far the most common cause of acute pharyngitis.
Risk factors for acute pharyngitis include all of the following EXCEPT:
- Age (older people are more vulnerable).
- Attendance at day care.
1. Age (older people are more vulnerable).
Younger patients are more vulnerable due to immature immune systems.
A new patient, aged 11 years, is suspected of having acute tonsillitis. The FNP would expect her to have which of the following symptoms?
- Oral lesions
- Tonsillar ulcers
- Dry cough
- Comorbid pulmonary disease
2. Tonsillar ulcers
There will be ulcers and/or exudate prominent on the affected tonsils. Pulmonary symptoms are common with RSV or mycoplasma pneumonia and oral lesions with acute stomatitis.
Treatment of the patient with acute tonsillitis will include all of the following EXCEPT:
- Assessment of airway obstruction.
- Judicious use of antibacterial mouthwash.
- Ofloxacin in appropriate dose.
- Warm salt water gargles.
3. Ofloxacin in appropriate dose.
Ofloxacin is a quinolone and should never be used in pediatric cases.
The most common etiology for enlarged cervical lymph nodes is:
- Human immunodeficiency virus.
- Common viral and bacterial infections.
- Dental abscess.
- Rheumatoid arthritis and other autoimmune diseases.
2. Common viral and bacterial infections.
Although all of the answers can cause cervical lymphadenopathy, viral and bacterial infections account for the majority of infections.
Infectious mononucleosis is found most often in which age group?
The highest recurrence rate is in those aged 15–25 years; 1–3% of college students experience IM annually.
After history and the physical exam, the FNP suspects a 22-year-old female has infectious mononucleosis. Of the following diagnostic studies that provide the most specific test, the result will be:
- A positive heterophile antibody test.
- A modest elevation of the white blood count.
- An elevated bilirubin.
- A decreased lymphocyte count.
1. A positive heterophile antibody test.
The heterophile antibody test is the confirming test in IM. It is present in 40–60% patients in the first week and 78–90% of cases by weeks 3–4.
The management plan for the patient with infectious mononucleosis will include:
- A course of systemic corticosteroids.
- Bed rest for 3–5 days.
- Avoidance of contact sports for 3–5 days.
- Increased clear fluids.
4. Increased clear fluids.
Increased fluids are an important supportive measure during the acute phase of IM. Increased activity levels increase the possibility of splenic rupture, and sports should be avoided for at least 4–6 weeks. Systemic corticosteroids are only used with complicated cases because they can affect cell-mediated immune response and may increase the risk of secondary bacterial infection.
A 67-year-old male presents with a 72-hour history of sore throat associated with nasal congestion, clear rhinorrhea, and slight cough. This is most likely:
- Epstein-Barr virus.
- Bacterial pharyngitis.
- Viral pharyngitis.
4. Viral pharyngitis.
Viral pharyngitis usually presents with associated respiratory symptoms. Patient is in the wrong age group for EB virus or RSV.
A 10-year-old male presents with a 2-week history of nosebleeds from both sides of his nose. They usually stop with pressure but have been becoming more frequent. They generally last about 5 minutes. The mother is concerned that her son might have a significant health problem. The exam will most probably reveal:
- Small sites of bleeding on the anterior nasal septum bilaterally.
- Dripping blood in the posterior pharynx.
3. Small sites of bleeding on the anterior nasal septum bilaterally.
This is most likely an anterior bleed (90%) in children. The other answers are indicative of a posterior bleed.
A 72-year-old male presents with the acute onset of unilateral epistaxis. He has been unable to stop the bleeding, which is a steady drip from his right naris. He has been coughing up bright red blood. He has hypertension and no history of previous episodes. This is most likely caused by:
- A foreign body.
- A posterior bleed.
- An anterior bleed.
- Cocaine abuse.
2. A posterior bleed.
This is most likely a posterior bleed because he has been coughing up bright red blood. A foreign body is unusual in this age group, as is cocaine abuse.
The most common cause of an upper respiratory infection is:
Rhinovirus is the most common cause of a URI. Bacteria can be a complication but is never the primary offending agent.
Which of the following is NOT true about allergic rhinitis?
- Poor sleep quality
- Peaks during young adulthood
- Results in decreased school concentration
- May exacerbate asthma
2. Peaks during young adulthood
Allergic rhinitis peaks during adolescence.
After evaluating a 22-year-old female, the FNP diagnoses allergic rhinitis. What testing could be performed?
- Sinus films
- Sinus CT
- Blood testing for allergies
- Blood chemistries
3. Blood testing for allergies
Imaging is not recommended for the diagnosis of allergies. A RAST or ELISA test could be done to see what allergies are present.
After the test is performed on the 22-year-old female from the previous question, what treatment will initially be prescribed?
- Oral antihistamine
- Leukotriene receptor antagonist
- Oral corticosteroid
- Topical decongestant
1. Oral antihistamine
Oral antihistamines are always the drug of choice to begin therapy.
Upon evaluating a 73-year-old male for nasal congestion, a "bad smell" is noted in his nose. This patient may have:
- Allergic rhinitis.
- Vasomotor rhinitis.
- Atrophic rhinitis.
- An upper respiratory infection.
3. Atrophic rhinitis.
Atrophic rhinitis is usually found in the elderly and is distinctive by its foul odor.
All of the following are risk factors for acute stomatitis EXCEPT:
- Day care attendance.
- Vitamin deficiency.
- Intact dentures.
4. Intact dentures.
Only poorly fitting dentures increase the risk for acute stomatitis.
Oral apthous ulcers appear as:
- Vesicles that break down to grayish ulcers.
- Small vesicles or ulcers only on the posterior pharyngeal wall.
- Small round or ovoid ulcers with circumscribed margins.
- Erythema of lips and oral mucosa.
3. Small round or ovoid ulcers with circumscribed margins.
Vesicles that break down to grayish ulcers are usually herpes simplex. Small vesicles on the posterior pharyngeal wall are usually indicative of herpangina. Erythema of the lips and oral mucosa is found in Kawasaki disease.
First-line treatment for the patient with apthous ulcers would include:
- Oral corticosteroids.
Valtrex may be used for RAU as an initial systemic treatment. The other medications must be reserved for severe cases.
The following is true of acute rhinosinusitis:
- An antibiotic is the only treatment.
- It is most common in adolescents and young adults.
- It is considered chronic if it lasts more than 2 months.
- The most common microbe involved is S. Pneumoniae.
4. The most common microbe involved is S. Pneumoniae.
All rhinosinusitis begins as a virus and only a small amount become infected with bacteria. It is most common in women between 45 and 64 years of age. It is considered chronic after 12 weeks of symptoms.
Predictive symptoms that a viral rhinosinusitis has become infected with bacteria include:
- Worsening symptoms > 5–7 days.
- Bilateral dental pain.
- Persistent hyposmia.
- Persistent symptoms for > 7 days.
1. Worsening symptoms > 5–7 days.
Dental pain is usually unilateral, and hyposmia is not a cardinal symptom for a bacterial super infection. Persistent symptoms should last >10 days before bacterial infection is suspected.
A 47-year-old female presents to the office with 3 days of nasal congestion with mucoid drainage, a dull frontal headache, and post nasal drip. She is concerned that she has a sinus infection. Treatment will include:
- High-dose Amoxicillin for 10 days.
- Watchful waiting with a backup of antibiotics if her symptoms worsen.
- Oral corticosteroids to decrease inflammation.
- Referral to a neurologist for a headache evaluation.
2. Watchful waiting with a backup of antibiotics if her symptoms worsen.
Watchful waiting is the best treatment plan at this stage because she has not been sick long enough to establish a bacterial diagnosis, and antibiotics are not necessary with her history.
A patient that was seen a week ago and diagnosed with a common cold returns today with worsening nasal congestion and headaches and purulent post nasal drip. She has a low-grade fever. Her exam reveals purulent drainage in the posterior pharynx and an edematous erythematous nasal chamber. Treatment will include:
- High-dose Amoxicillin for 10–14 days.
- Referral to otolaryngology.
- Ordering a CT scan of the sinuses.
- Avelox 400 mg for 14 days.
1. High-dose Amoxicillin for 10–14 days.
Amoxicillin is an initial choice for uncomplicated bacterial rhinosinusitis. It is too early to order a CT scan or make a referral.
The FNP is performing a risk assessment on a 9-month-old female infant with a history of two previous episodes of AOM. Which of the following is NOT a risk factor?
- Second-hand smoke
- Bottle feeding in upright position
- Day care with seven children
- Pacifier use
2. Bottle feeding in upright position
Bottle feeding in the SUPINE position presents a risk for AOM.
The tympanic membrane of a child with an otitis media with effusion will appear:
- With increased vascular markings.
A bulging erythematous tympanic membrane with hyperemia are signs of acute otitis media.
A 5-month-old male infant has a documented acute otitis media. He appears ill with a fever of 103.2 degrees F. The mother is a reliable witness. The treatment plan would include:
- Observation of the patient to see if he improves over the next 24–48 hours.
- Sending him to the emergency room because he is so ill.
- Placing him on amoxicillin suspension at the appropriate dose if he has no known allergy.
- Explaining to the mother that no treatment is needed but he should be followed up in 2 weeks.
3. Placing him on amoxicillin suspension at the appropriate dose if he has no known allergy.
An infant under the age of 5 months should be treated with an antibiotic but does not need emergency care. The mother can report his progress by phone in 24–48 hours to ascertain efficacy of the antibiotic.
A 4-year-old female patient has otitis media with effusion following an initial episode of acute otitis media 2 months ago. She is experiencing no hearing loss and has no speech problems. Which of the following is the best next step?
- Tell the patient’s parents that this is within normal limits for resolution and to make a follow-up appointment in 4 weeks.
- Refer her to an otolaryngologist.
- Place the patient on a decongestant or antihistamine.
- Use Augmentin in appropriate doses.
1. Tell the patient’s parents that this is within normal limits for resolution and to make a follow-up appointment in 4 weeks.
It is too soon to refer this patient because there is a 40% presence of effusion at 4 weeks. Decongestants, antihistamines, and antibiotics are not effective in OME.
Prevention measures for AOM/OME include:
- Choosing a day care with at least 20 children.
- Making sure that an antibiotic is used with each episode.
- Allowing infants to bottle feed in the supine position only.
- Preventing exposure to second-hand smoke.
4. Preventing exposure to second-hand smoke.
The smaller the day care center, the less the risk; 20 children is too great a number. Antibiotics are not indicated in OME and infants should always be bottle-fed in the upright position.
During examination of a 4-year-old male child, it is noted that the left tympanic membrane is dull and immobile. The FNP suspects that he has an associated hearing loss. This type of hearing loss is most likely:
Conductive hearing loss is most prevalent in children. The presence of a dull and immobile tympanic membrane suggests the presence of fluid behind the TM, which is associated with conductive hearing loss.
A 7-year-old female child is doing poorly in school and her grades are falling. She is having problems concentrating and her mother is concerned about her ability to hear the teacher. She has a long history of acute and chronic ear infections. A conductive hearing loss is suspected. The FNP expects to find the following:
- A Weber test that lateralizes to the unaffected ear
- A Rinne test where air conduction = bone conduction
- An audiometric test from school showing an "air-bone gap"
- A tympanometry test showing no negative pressure
3. An audiometric test from school showing an "air-bone gap"
In conductive hearing loss, the Weber test lateralizes to the affected ear, and the Rinne test will show bone conduction greater than air conduction. The tympanogram will show negative pressure or immobility.