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1) A) Apical and radial pulses at the same time, then finding the difference between the two.

The pulse deficit is determined by counting the apical and radial pulses at the same time,
then subtracting to find the difference between the two.
2) B) Serum creatinine and potassium levels Native Americans have a much higher rate of
kidney disease and renal failure when compared to other races. Native Americans have a 1
in 3 incidence of hypertension. Hypertension is the second leading cause of kidney failure.
BUN, creatinine, estimated GFR, and uri- nalysis are performed to assess the function of the
kidneys.
3) B) Chronic hypertension The most common cause of LVH is chronic hypertension.
4) A) Premedicate himself 20 minutes prior to starting exercise Exercise-induced asthma is
best controlled by using the Proventil inhaler (bronchodilator) approxi- mately 20 minutes
prior to exercise, to prevent vasospasm of the bronchioles and shortness of breath with
exercise. These bronchodilators usually last approxi- mately 4 hours. They also work quickly
to open up the bronchioles if an acute attack/shortness of breath occurs.
5) C) The scotch tape test Enterobiasis infection (pinworms) is caused by small worms that
infect the intestines. Symptoms include itching around the anus, which is usually worse at
night. The scotch tape test is done by applying the scotch tape on the anal area in the
morning; the worms commonly come out at night and will stick to the tape, which is used for
diagnosis.
6) C) Moderate persistent asthma Asthma classifications: Intermittent: normal FEV between
exacerbations, FEV > 80%; mild persistent, FEV > 80%; moderate persistent, FEV 6080%;
severe persistent, FEV < 60%.
7) D) Psoriasis Auspitz sign is the presence of pinpoint bleeding spots from psoria- sis where
the skin is scraped off.
8) C) A long-acting oral theophylline (Theo-Dur) 200 mg every 12 hours Theo- phylline is used
to control inflammation of the lungs. Tilade, Intal, and Flovent help to treat inflammation.
9) A) A patch of leukoplakia An early sign of HIV is a hairy patch of leukoplakia on the tongue.
10) B) Mitral stenosis Mitral stenosis is best heard at the fifth ICS to the left of the midclavicular
line. It is ausculated as a low-pitched diastolic murmur, grade II/ VI. Aortic regurgitation is a
high-pitched diastolic murmur, heard at the second ICS to the right of the sternum. Mitral
regurgitation is a pansystolic murmur that radiates to the axilla, loud and high pitched when
ausculated.
11) B) Decreased mobility of the tympanic membrane as measured by tympano-gram Fluid
behind the ear drum will decrease the mobility of the TM when mea- sured by a
tympanogram. When perforation occurs, discharge will flow through the pars tensa portion
of the ear drum.
12) C) Status asthmaticus Pulsus paradoxus is most likely to be seen with status asthmaticus.
With inspiration, systolic pressure drops due to the increased pres- sure (positive pressure).
Some pulmonary risks of having increased pressure include asthma and emphysema.
Cardiac causes for pulsus paradoxus include tamponade, pericarditis, and cardiac effusion.

13) B) Increase only the NPH insulin in the morning Increase in the morning NPH is
recommended to affect the late afternoon blood sugar readings. Increasing the NPH will
lower the afternoon blood sugar readings. NPH is a long-acting insulin, with onset beginning
12 hours and peaking in approximately 68 hours. Duration of NPH is approximately 1824
hours.
14) D) Calcium channel blockers Common side effects of calcium channel blockers include
headaches, edema of the lower extremities, and heart block or bradycardia.
Contraindications for calcium channel blockers include second- or third-degree AV block,
bradycardia, and congestive heart failure.
15) D) Penicillin (Pen VK) Pen VK is safe to use for strep throat during pregnancy. Pen VK is a
category B medication for pregnancy and lactation.
16) A) Central vision The cones of the eyes are responsible for central vision.
17) A) 3 months The posterior fontanelle normally closes by 3 months of age. The anterior
fontanelle closes between 12 and 18 months of age.
18) C) Edema of the ankles and headache Common side effects of calcium channel blockers,
such as Procardia, include edema of the ankles, dizziness, headaches, flushing, and
weakness. ACE inhibitors tend to have the side effects of angioedema and a dry hacking
cough. Diuretics can cause hyperkalemia and hyperuricemia.
19) A) The veins are larger than the arterioles On funduscopic exam of the eye you will see that
the veins are larger in size than the arterioles.
20) D) Migraine headaches Contraindications with Betimol (timolol) include heart fail- ure or
sinus bradycardia, asthmatic patients, and second- or third-degree AV block.
21) C) It is best heard at the apex at S1 Mitral regurgitation is best heard at the api- cal area; it is
a high-pitched, blowing pansystolic murmur.
22) A) Metronidazole (Flagyl) Trichomoniasis symptoms include dysuria, severe vaginal pruritis,
and malodorous vaginal discharge. Wet prep will show trichomonads that are pear-shaped
and have several flagella (whiplike tails) at one end. CDC recommendation for treatment is
metronidazole.
23) D) 12 months The earliest age that MMR is recommended is 12 months. This age is
recommended because giving it any earlier may be less effective because the infant still has
antibodies from the mother. Antibodies still present from the mother may interfere with the
production of the antibodies stimulated by the MMR vaccine.
24) A) Mumps virus Orchitis is caused by the mumps virus.
25) B) Patient is coherent Characteristics of delirium include an acute and dramatic onset of
symptoms that is temporary, and usually will worsen in the evening. May last hours to days.
Patient is incoherent and disoriented. Usually brought on by fever, shock, drugs, alcohol, or
dehydration.
26) D) Bartholins gland abscess Bartholins glands are located in the base of the labia minora
at about the 4 oclock and 8 oclock positions. Their function is to provide moisture for the
vestibule. They are small (about pea sized) unless they become clogged or infected. If

glands become clogged or infected, an abscess may form and glands will enlarge and
become painful.
27) B) Amenorrhea One common side effect seen in women who have been taking DepoProvera for more than 5 years is amenorrhea. It is a progesterone hormone that causes
cessation of periods.
28) D) Stroking the inner thigh of a male client and watching the testicle on the ipsilateral side
rise up toward the body The cremasteric reflex test is done by stroking the inner thigh of a
male client and watching for the testicle on the ipsi- lateral side to rise up toward the body.
29) C) Serum folate acid and B12 level Serum folate acid and B12 levels would be ordered to
evaluate him for folic acid deficiency anemia. Many patients who are deficient in folic acid
are also deficient in B12.
30) D) Microaneurysms Microaneurysms are seen with diabetic retinopathy. AV nicking, copper
wire arterioles, and flame hemorrhages are seen with uncontrolled hypertension.
31) B) T-score between 1. 0 and 2.5 Osteopenia is defined as a t-score between 1. 0 and
2.5. Osteoporosis is defined as a t-score of less than 2.5.
32) C. Risk factors for AAA include smoking, hypertension, and periph- eral vascular disease. A
bicuspid aortic valve is usually asymptomatic and does not place the patient at risk for aortic
aneurysms.
33) B. When an AAA reaches 5.5 cm or greater, surgery usually is indi- cated because the risk
of rupture is increased. For asymptomatic aneurysms smaller than 5 cm, the 5-year risk of
rupture is less than 1% to 2%, so serial noninvasive monitoring is an alternative strategy.
34) D. The most common cause of a mass lesion of the brain in an HIV patient is toxoplasmosis,
which is treated with sulfadiazine with pyrimethamine.
35) B. The serum acetaminophen level of 30 g/mL, with last ingestion 8 hours previously, is
plotted on the nomogram and falls below the danger zone of possible hepatic injury. Thus,
this patient should be observed. Sometimes, patients will take more than one medica- tion
so that serum and/or urine drug testing may be worthwhile. Gastrointestinal activated
charcoal, not intravenous charcoal, is used for other ingestions.
36) E. Idiopathic or autoimmune hepatitis is a less-well-understood cause of hepatitis that
seems to be caused by autoimmune cell- mediated damage to hepatocytes. A subgroup of
these patients includes young women with positive ANAs and hypergammaglob- ulinemia
who may have other symptoms and signs of systemic lupus erythematosus.
37) B. Hemochromatosis is a genetic disorder of iron metabolism. Progressive iron overload
leads to organ destruction. Diabetes mellitus, cirrhosis of the liver, hypogonadotrophic
hypogonadism, arthropa- thy, and cardiomyopathy are among the more common end-stage
developments. Skin deposition of iron leads to bronzing of the skin, which could be
mistaken for a tan. Diagnosis is made early in the course of disease by demonstrating
elevated iron stores but can be made through liver biopsy with iron stains. Genetic testing is
avail- able. Therapy involves phlebotomy to remove excess iron stores.
38) D. Sclerosing cholangitis is an autoimmune destruction of both the intrahepatic and
extrahepatic bile ducts and often is associated with inflammatory bowel disease, most

commonly ulcerative colitis. Patients present with jaundice or symptoms of biliary


obstruction; cholangiography reveals the characteristic beading of the bile ducts.
39) C. Primary biliary cirrhosis is thought to be an autoimmune disease leading to destruction of
small- to medium-size bile ducts. Most patients are women between the ages of 35 and 60
years, who usually present with symptoms of pruritus and fatigue. An alkaline phos- phatase
level elevated two to five times above the baseline in an oth- erwise asymptomatic patient
should raise suspicion for the disease. No specific therapy is available.
40) A. Wilson disease is an inherited disorder of copper metabolism. The inability to excrete
excess copper leads to deposition of the mineral in the liver, brain, and other organs.
Patients can present with ful- minant hepatitis, acute nonfulminant hepatitis, or cirrhosis, or
with bizarre behavioral changes as a result of neurologic damage. Kayser- Fleischer rings
develop when copper is released from the liver and deposits in Descemet membrane of the
cornea.
41) The correct answer is B, phlebotomy. PV is a disorder that causes overproduction of RBCs.
42) The correct answer is D, Selenium sulfide. Pityriasis versicolor is caused by a yeast.
43) The correct answer is E, Rubeola. The symptoms are pathognomonic for Rubeola
(Measles).
44) The correct answer is C. All others are seen in conductive hearing loss.
45) The correct answer is E. Right ventricular enlargement occurs because of an increase in
pulmonary pressure. The RVH causes right axis deviation.
46) The correct answer is B, Atenolol. Beta blockers can mask signs of hypoglycemia (eg.
Tachycardia) and should be used sparingly.
47) The correct answer is A. Mitral valve murmurs are best heard on left side at the apical
impulse.
48) The correct answer is D. Bullous myringitis is the complication associated with Mycoplasma.
49) The correct answer is B. The symptoms must be present for a designated period of time.
50) The correct answer is C. The results of therapy is most accurately seen on spirometry.
51) The correct answer is B, Adenosine. It is first line in the treatment of paroxysmal
supraventricular tachycardia.
52) The correct answer is D. You want to start warfarin, but cover with heparin until therapeutic
levels of warfarin are reached.
53) The correct answer is A. The patients bradycardia is severe, probably a result of an inferior
MI. Atropine is the agent of choice in this situation. Mobitz I heart block has a good
prognosis (vs complete heart block), so transvenous pacing is not required.
54) The correct answer is A. Fistulas are common with Crohns disease because of its
transmural nature, but are uncommon with ulcerative colitis.
55) The correct answer is B. Renal ultrasound is the next appropriate step to assess for
hydronephrosis and to evaluate for bilateral ureteral obstructions, which are common sites of
metastases of cervical cancer. Her physical examination and urine studies (showing a FE >

1%) are inconsistent with hypovolemia, so intravenous infusion is unlikely to improve her
renal function. Use of loop diuretics may increase her urine output somewhat but does not
help to diagnose the cause of her renal failure or to improve her outcome. Further imaging
may be necessary after the ultrasound, but use of intravenous contrast at this point may
actually worsen her renal failure.
56) C. This individual is suffering from heat exhaustion, which can lead to rhabdomyolysis and
release of myoglobin. Myoglobinuria leads to a reddish appearance and positive urine
dipstick reaction for blood, but microscopic analysis of the urine likely will demonstrate no
red cells.
57) C. The antistreptolysin-O titers typically are elevated and serum complement levels are
decreased in poststreptococcal GN.
58) D. Goodpasture (antiglomerular basement membrane) disease typically affects young
males, who present with hemoptysis and hematuria. Antibody against type IV collagen,
expressed in the pulmonary alveolar and glomerular basement membrane, leads to the
pulmonary and renal manifestations. Hypertension typically is absent. After the initial clinical
signs, renal insufficiency usually progresses rapidly. Anti-GBM antibodies almost always are
present; the gold standard for diagnosis is renal biopsy.
59) The correct answer is B. The patients country of origin, the chronic and slowly progressive
nature of the pain in association with the fever, and night sweats are highly suggestive of TB
osteomyelitis of the spine or Potts disease. Bacterial osteomyelitis presents more acutely,
often with high, spiking fevers. Metastatic breast cancer and MM are extremely rare in this
age group.
60) The correct answer is C. Listeria monocytogenes is a gram-positive rod that causes appx
10% of all cases of meningitis. It is more common in the elderly and in patients with impaired
cell-mediated immunity. It is also more common in neonates. It is NOT sensitive to
cephalosporins, and specific therapy with ampicillin must be given.

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