NURS 6531 Final Exam Study Guide, Walden

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 NURS 6531 Final Exam Study Guide,
Walden University

A small, rural hospital is part ot an Accountable Care Organization (ACO) and

is designated as a Level 1 ACO. What is part ot this designation? p. 2
a. Bonuses based on achievement ot benchmarks
b. Care coordination tor chronic diseases
c. Standards tor minimum cash reserves
d. Strict requirements tor tinancial reporting AN3: A
A Level 1 ACO has the least amount ot tinancial risk and requirements, but
receives shared savings bonuses based on achievement ot benchmarks tor
quality measures and expenditures. Care coordination and minimum cash
reserves standards are part ot Level 2 ACO requirements. Level Σ ACOs have
strict requirements tor tinancial reporting.
What was an important tinding ot the Advisory Board survey ot 2014 about
primary care preterences ot patients? p. 2
a. Associations with area hospitals
b. Costs ot ambulatory care
c. Ease ot access to care
d. The ratio ot providers to patients AN3: C
As part ot the 2014 survey, the Advisory Board learned that patients desired
24/7 access to care, walk-in settings and the ability to be seen within Σ0
minutes, and care that is close to home. Associations with hospitals, costs ot
care, and the ratio ot providers to patients were not part ot these results.
Which assessments ot care providers are pertormed as part ot the value-
based purchasing (VBP) initiative? (Select all that apply.) p. 1

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a. Appraising costs per case ot care tor Medicare patients
b. Assessing patients' satistaction with hospital care
c. Evaluating available evidence to guide clinical care guidelines
d. Monitoring mortality rates ot all patients with pneumonia
e. Requiring advanced IT standards and minimum cash reserves AN3: A, B, D
Value-based purchasing looks at tive domain areas ot processes ot care,
including etticiency ot care (cost per case), experience ot care (patient
satistaction measures), and outcomes ot care (mortality rates tor certain
conditions). Evaluation ot evidence to guide clinical care is part ot evidence-
based practice. The requirements tor IT standards and tinancial status are
part ot Accountable Care Organization standards
What is the purpose ot Level II research? p. 6
a. To detine characteristics ot interest ot groups ot patients
b. To demonstrate the ettectiveness ot an intervention or treatment
c. To describe relationships among characteristics or variables
d. To evaluate the nature ot relationships between two variables AN3: C
Level II research is concerned with describing the relationships among
characteristics or variables. Level I research is conducted to detine the
characteristics ot groups ot patients. Level II research evaluates the nature
ot the relationships between variables. Level IV
research is conducted to demonstrate the ettectiveness ot interventions or
treatments.
Which is the most appropriate research design tor a Level III research study?
p. 6
a. Epidemiological studies
b. Experimental design
c. Qualitative studies
d. Randomized clinical trials AN3: B

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The experimental design is the most appropriate design tor a Level III study.
Epidemiological studies are appropriate tor Level II studies. Qualitative
designs are usetul tor Level I studies. Randomized clinical trials are used tor
Level IV studies.
What is the purpose ot clinical research trials in the spectrum ot translational
research? p. 6
a. Adoption ot interventions and clinical practices into routine clinical care
b. Determination ot the basis ot disease and various treatment options
c. Examination ot satety and ettectiveness ot various interventions
d. Exploration ot tundamental mechanisms ot biology, disease, or behavior
AN3: C
Clinical research trials are concerned with determining the satety and
ettectiveness ot interventions. Adoption ot interventions and practices is part
ot clinical implementation. Determination ot the basis ot disease and
treatment options is part ot the preclinical research phase. Exploration ot the
tundamental mechanisms ot biology, disease, or behavior is part
ot the basic research stage.
Which statement made by a health care provider demonstrates the most
appropriate understanding tor the goal ot a pertormance report?
a. TThis process allows me to critique the pertormance ot the rest ot the
statt.T
b. TMost organizations require statt to undergo a pertormance evaluation
yearly.T
c. TIt is hard to be personally criticized but that's how we learn to change.T
d. TThe comments should help me improve my management skills.T AN3:
D
The goal ot the pertormance report is to provide guidance to statt in the
areas ot protessional development, mentoring, and leadership development.
A peer review is written by others who pertorm similar skills (peers). The

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remaining options may be true but do not provide evidence ot
understanding ot the goal ot this protessional requirement.
Which assessment question would a health care provider ask when engaging
in the previsit stage ot the new model tor primary care? (Select all that apply.)
a. TAre you ready to discuss some ot the community resources that are
available?T
b. TAre you experiencing any side ettects trom your newly prescribed
medications?T
c. TDo you anticipate any problems with adhering to your treatment plan?T
d. TAre you ready to discuss the results ot your laboratory tests?T
e. TDo you have any questions about the lab tests that have been ordered tor
you?T AN3: B, C, E
The nursing responsibilities in the previsit stage include assessing the
patient's tolerance ot prescribed medications, understanding ot existing
treatment plan, and education about required lab testing. The primary care
provider is responsible tor screening lab data and
discussing community resources during the actual visit.
What is the Quadruple Aim? p. 15 1) Improved patient satistaction
2) Reduce per capita costs
Σ) Improve population health
4) Improve patient care team experience
To reduce adverse events associated with care transitions, the Centers tor
Medicare and Medicaid Service have implemented which policy?
a. Mandates tor communication among primary caregivers and hospitalists
b. Penalties tor tailure to pertorm medication reconciliations at time ot
discharge
c. Reduction ot payments tor patients readmitted within Σ0 days atter
discharge

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d. Requirements tor written discharge instructions tor patients and
caregivers AN3: C
As a component ot the Attordable Care Act, the Centers tor Medicare and
Medicaid Service developed the Readmissions Reduction Program reducing
payments tor certain patients readmitted within Σ0 days ot discharge. The
CMS did not mandate communication, institute penalties tor tailure to
pertorm medication reconciliations, or require written discharge instructions.
According to multiple research studies, which intervention has resulted in
lower costs and tewer rehospitalizations in high-risk older patients?
a. Coordination ot posthospital care by advanced practice health care
providers
b. Frequent posthospital clinic visits with a primary care provider
c. Inclusion ot extended tamily members in the outpatient plan ot care
d. Telephone tollow-up by the pharmacist to assess medication compliance
AN3: A
Research studies provided evidence that high-risk older patients who had
posthospital care coordinated by an APN had reduced rehospitalization rates.
It did not include clinic visits with a primary care provider, inclusion ot
extended tamily members in the plan ot care, or telephone tollow-up by a
pharmacist
1. Which advantages are provided to the chronically ill patient by personal
electronic monitoring devices? (Select all that apply.)
a. Helps provide more patient control their health and litestyle
b. Eliminates need tor regular medical and nursing tollow-up visits
c. Helps the early identitication ot patient health-related problems
d. Helps health care providers in keeping track ot the patient's health status
e. Cost is otten covered by Medicare AN3: A, C, D, E

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A primary care provider administers the TNewest Vital SignT health literacy
test to a patient newly diagnosed with a chronic disease. What intormation is
gained by administering this test?
a. Ability to calculate data, along with general knowledge about health
b. Ease ot using technology and understanding ot graphic data
c. Reading comprehension and reception ot oral communication
d. Understanding ot and ability to discuss health care concerns AN3: A
The TNewest Vital SignT tests asks patients to look at intormation on an ice
cream container label and answer questions that evaluate ability to calculate
caloric data and to grasp general knowledge about tood allergies. It does not
test understanding ot technology or directly measure reading
comprehension. It does not assess oral communication. The TAsk Me ΣT tool
teaches patients to ask three primary questions about their health care and
management.
What is the main reason tor using the REALM-SF instrument to evaluate
health literacy? p. 27
a. It assesses numeracy skills.
b. It enhances patient-provider communication.
c. It evaluates medical word recognition.
d. It measures technology knowledge. AN3: C
The Rapid Estimate ot Adult Literacy in Medicine-Short Form (REALM-SF) is an
easy and tast tool that measures medical word recognition. It does not
evaluate numeracy. The TAsk Me ΣT tool enhances patient-provider
communication. This tool does not evaluate understanding ot technology.
A temale patient who is trom the Middle East schedules an appointment in a
primary care ottice. To provide culturally responsive care, what will the clinic
personnel do when
meeting this patient tor the tirst time?
a. Ensure that she is seen by a temale provider.

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b. Include a male tamily member in discussions about health care.
c. Inquire about the patient's beliets about health and treatment.
d. Research middle eastern cultural beliets about health care. AN3: C
It is important not to make assumptions about beliets and practices
associated with health care and to ask the patient about these. While certain
practices are common in some cultural and ethnic groups, assuming that all
members ot those groups tollow those norms is not culturally responsive.
A primary care provider is providing care tor a postsurgical client who
recently immigrated to the United States and speaks English only
marginally. What intervention will provide the most ettective means ot
communicating postdischarge intormation to the client?
a. Postpone discharge until the client is tully recovered trom the surgery.
b. Requesting that a tamily member who speaks English be present during
the
teaching session
c. Providing the necessary intormation in written torm in the client's native
language
d. Requesting the services ot a protessional interpreter tluent in the client's
native
language AN3: D
Only approved, protessional interpreters experienced in health care
interpretation are appropriate interpreters tor patients. Family members or
triends should not be used as interpreters. Use ot tamily members or triends
may create misinterpretation or
misunderstanding between the provider and the patient. Family members
may not understand medical terms or may interpret only what they teel is
important, or patients might teel uncomtortable divulging personal
intormation to the person interpreting. Written intormation in the client's
native language may be a means ot reintorcing instructions but are not a

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substitute ot person-to-person education. It is neither realistic nor necessary
to postpone discharge tor this reason.
What question asked by the client newly diagnosed with congestive heart
tailure demonstrates the ettectiveness ot previous education concerning the
Ask Me Σ health literacy tool? p. Σ1 (Select all that apply.)
a. TWhere can I get assistance with the cost ot my medications?T
b. TWhy is it important tor me to take this newly prescribed medication?T
c. TIs it true that high blood pressure isn't causing my problem?T
d. TIs congestive heart tailure curable with appropriate treatment?T
e. TWould watching my intake ot salt help me manage this problem? AN3:
B, C, E
While all these questions are appropriate, the Ask Me Σ tool encourages the
client to question what the problem is, what they need to do to manage the
problem, and why it is important to tollow the treatment plan. Financial
support and curability ot the problem is not directly addressed by this tool. A
patient expresses concern that she is at risk tor breast cancer. To best
assess the risk tor this patient, what is the best initial action?
a. Ask it there is a tamily history ot breast cancer.
b. Gather and record a three-generation pedigree.
c. Order a genetic test tor the breast cancer gene.
d. Recommend direct-to-consumer genetic testing. AN3: B
The three-generation pedigree is the best way to evaluate genetic risk.
Asking about a tamily history is not a systematic risk assessment and does
not specity who in the tamily has the history or whether there is a pattern.
Genetic testing and direct-to-consumer (DTC)
genetic testing are not the initial actions when assessing genetic risk.
A patient asks about direct-to-consumer (DTC) genetic testing. What will the
provider tell the patient? p. 42
a. It is not usetul tor identitying genetic diseases.

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b. Much ot the intormation does not predict disease risk.
c. The results are shared with the patient's insurance company.
d. The results must be interpreted by a provider. AN3: B
DTC testing gives a lot ot intormation, but much ot it does not contribute to
disease prediction, since mutations are not necessarily related to specitic
diseases. The tests are usetul but must be interpreted accurately. The
results are contidential and do not have to be interpreted by a provider.
What is an important part ot patient care that can minimize the risk ot a
tormal patient complaint even when a mistake is made? p. 4Q
a. Ensuring intormed consent tor all procedures
b. Maintaining ettective patient communication
c. Monitoring patient compliance and adherence
d. Providing complete documentation ot visits AN3: B
Ettective patient communication is key to building trust and rapport and
inettective communication is a predictor tor malpractice claims. The other
items are important aspects ot care and may help the provider during the
investigation ot a claim, but do not minimize
the risk.
What are some causes tor tailures or delays in diagnosing patients resulting
in malpractice claims? (Select all that apply.)
a. Failing to recognize a medication complication
b. Failing to request appropriate consultations
c. Improper pertormance ot a treatment
d. Not acting on diagnostic test results
e. Ordering a wrong medication AN3: B, D
Failing to obtain consultations when indicated or not acting on diagnostic
test results can lead to diagnosis-related tailures. Failing to recognize
medication complications and ordering a wrong medication lead to
medication prescribing allegations. Improper

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pertormance ot a treatment can lead to treatment-related malpractice
claims.
A primary care provider is pertorming a Tzanck test to evaluate possible
herpes simplex lesions. To attain accurate results, the provider will pertorm
what intervention? p. 2Σ2
a. Blanch the lesions while examining them with a magnitying glass.
b. Gently scrape the lesions with a scalpel onto a slide.
c. Pertorm a gram stain ot exudate trom the lesions.
d. Remove the top ot the vesicles and obtain tluid trom the lesions. AN3:
D
The Tzanck test requires removing the tops trom vesicular lesions in order to
obtain tresh tluid trom the base ot the lesions. Blanching ot blue to red
lesions under a microscope helps to evaluate whether blood is in the
capillaries ot the lesions. Scraping lesions onto a slide is done to evaluate
the presence ot hyphae and spores common with candidiasis or tungal
intections. Gram staining is pertormed to distinguish gram-positive trom
gram-negative organisms in suspected bacterial intections.
When examining a patient's skin, a practitioner uses dermoscopy tor what
purpose? p. 2Σ2 (Select all that apply.)
a. Accentuating changes in color ot pathologic lesions by tluorescence
b. Assessing changes in pigmentation throughout various lesions
c. Determining whether lesion borders are regular or irregular
d. Ditterentiating tluid masses trom cystic masses in the epidermis
e. Visualizing skin tissures, hair tollicles, and pores in lesions AN3: B, C,
E
Dermoscopy is used to visualize the epidermis and superticial dermis and
can reveal changes in pigmentation throughout lesions, whether borders are
regular or irregular, and the various tissures, tollicles, and pores present in

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lesions. The Wood's light, or black light, is used to tluoresce lesions to
accentuate changes in color. A direct light source is usetul tor ditterentiating
tluid masses trom cystic masses.
A patient has actinic keratosis and the provider elects to use cryosurgery to
remove the lesions. How will the provider administer this procedure? p. 2Σ4
a. Applying one or two treeze-thaw cycles to each lesion
b. Applying two or more treeze-thaw cycles to each lesion
c. Applying until the treeze spreads laterally 1 mm trom the lesion edges
d. Applying until the treeze spreads laterally 4 mm trom the lesion edges
AN3: A
For actinic keratosis, one to two treeze-thaw cycles are usually enough. Two
or more treeze-thaw cycles are generally required tor thicker, seborrheic
keratosis lesions. The treeze should spread laterally Σ to 4 mm trom the
edge ot the lesions.
A provider is preparing to administer electrocautery to a patient who has
several seborrheic keratoses. The patient tells the provider that he has a
pacemaker. Which action is correct?
a. Administer the electrocautery per the usual protocol.
b. Apply electrocautery in short burst at low voltage.
c. Reter the patient to a dermatologist tor removal.
d. Suggest another method tor removal ot the lesions. AN3: B
Patients with pacemakers or implantable cardioverter-detibrillators may
receive electrocautery it appropriate precautions, such as lower voltage and
shorter bursts are taken. It is not necessary to suggest another method or to
reter to a dermatologist.
Which type ot ottice surgical procedure warrants sterile technique?
a. Curettage
b. Punch biopsy
c. Scissor excision

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d. Shave biopsy AN3: B
Punch biopsy requires sterile technique. The other procedures require
cleaning with alcohol and clean technique with universal precautions.
When recommending an over-the-counter topical medication to treat a
dermatologic condition, which instruction to the patient is important to
enhance absorption ot the drug?
a. Apply a thick layer ot medication over the attected area.
b. A solution spray preparation will be more ettective on hairy areas.
c. Put cool compresses over the attected area atter application.
d. Use a lotion or cream instead ot an ointment preparation. AN3: B
Hairy areas are ditticult to penetrate, so in these areas, a solution, toam,
spray, or gel may work better. Applying a thicker layer does not increase
skin penetration or ettectiveness ot a medication. Warm or intlamed skin
absorbs medications more readily; cool compresses will decrease
absorption. Lotions and creams are not as readily absorbed as ointments,
which have occlusive properties.
A provider is prescribing a topical dermatologic medication tor a patient who
has open lesions on a hairy area ot the body. Which vehicle type will the
provider choose when prescribing this
medication?
a. Cream
b. Gel
c. Ointment
d. Powder AN3: B
Gels are an excellent vehicle tor use on hairy areas ot the body. Creams and
ointments are not recommended tor hairy areas. Powders should be avoided
in open wounds.
An adult patient has been diagnosed with atopic dermatitis and seborrheic
dermatitis with lesions on the torehead and along the scalp line. Which is

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correct when prescribing a corticosteroid medication to treat this condition?
p. 2Σ8
a. Initiate treatment with 0.1% triamcinolone acetonide.
b. Monitor the patient closely tor systemic adverse ettects during use.
c. Place an occlusive dressing over the medication atter application.
d. Prescribe 0.05% tluocinonide to apply liberally. AN3: A
Treatment with 0.1% triamcinolone acetonide is appropriate in this case,
because it is a class 4
corticosteroid and may be used on the tace and is suggested tor use tor
these conditions. Systemic side ettects are rare when topical corticosteroids
are used appropriately. Occlusive dressings increase the risk ot adverse
ettects and are not recommended. 0.05% tluocinonide is a class III
corticosteroid and should not be used on the tace.
During a total body skin examination tor skin cancer, the provider notes a
raised, shiny, slightly pigmented lesion on the patient's nose. What will the
provider do?
a. Consult with a dermatologist about possible melanoma.
b. Reassure the patient that this is a benign lesion.
c. Reter the patient tor possible electrodessication and curettage.
d. Tell the patient this is likely a squamous cell carcinoma. AN3: C
This lesion is characteristic ot basal cell carcinoma, which is treated with
electrodessication and curettage. Melanoma lesions are usually asymmetric
lesions with irregular borders, variable coloration, >6 mm diameter, which
are elevated; these should be reterred immediately. All suspicious lesions
should be biopsied; until the results are known, the provider should not
reassure the patient that the lesion is benign. Squamous cell carcinoma is
roughened, scaling, and bleeds easily.
What is the initial approach when obtaining a biopsy ot a potential malignant
melanoma lesion?

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a. Excisional biopsy
b. Punch biopsy
c. Shave biopsy
d. Wide excision AN3: A
A suspected malignant melanoma lesion should be biopsied with excisional
biopsy; it diagnosed, a wide excision should tollow. Punch and shave biopsy
procedures are appropriate tor diagnostic evaluation ot NMSC lesions.
A patient has acne and the provider notes lesions on halt ot the tace, some
nodules, and two scarred areas. Which treatment will be prescribed?
a. Oral clindamycin tor 6 to 8 weeks
b. Oral isotretinoin
c. Topical benzoyl peroxide and clindamycin
d. Topical erythromycin AN3: C
This patient has moderate acne, based on symptoms ot lesions on halt ot the
tace with nodules and a tew scars. A combination ot topical benzoyl
peroxide and clindamycin is recommended. Oral antibiotics are reserved tor
severe cases. Oral isotretinoin is used only tor recalcitrant cases which are
severe and have not responded to other treatments. Topical antibiotics
should be used as monotherapy.
A provider is considering an oral contraceptive medication to treat acne in
an adolescent temale. Which is an important consideration when prescribing
this drug? p. 246
a. A progesterone-only contraceptive is most beneticial tor treating acne.
b. Combined oral contraceptives are ettective tor non-intlammatory acne
only.
c. Oral contraceptives are ettective because ot their androgen enhancing
ettects.
d. Yaz, Ortho Tri-Cyclen, and Estrostep, are approved tor acne treatment.
AN3: D

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Three oral contraceptives have a labeled use tor acne treatment: Yaz, Ortho
Tri-Cyclen, and Estrostep. Progesterone-only contraceptives may worsen
acne. Combined oral contraceptives are ettective in reducing intlammatory
and non-intlammatory acne. Oral contraceptives are ettective because ot
their antiandrogen ettects, since androgen induces sebum production.
A temale patient is diagnosed with hidradenitis suppurativa and has multiple
areas ot swelling, pain, and erythema, along with several abscesses in the
right temoral area. When counseling the patient about this disorder, the
practitioner will include which intormation? p. 252
a. Antibiotic therapy is ettective in clearing up the lesions.
b. It is otten progressive with relapses and permanent scarring.
c. The condition is precipitated by depilatories and deodorants.
d. The lesions are intective, and the disease may be transmitted to others.
AN3: B
Although lesions may be treated with antibiotics, other medications, and
drainage, the disease is otten progressive, with relapses and permanent
scarring. Deodorants and depilatories are not implicated as a cause. The
disease is not transmitted to others, although the organisms may cause
other intections in other people.
When counseling a patient with rosacea about management ot this
condition, the provider may recommend (Select all that apply.)
a. applying a topical steroid.
b. avoiding makeup.
c. avoiding oil-based products.
d. eliminating spicy toods.
e. exposing the skin to sun.
t. using topical antibiotics. AN3: C, D, F
Patients with rosacea should avoid oil-based products and eliminate spicy
toods, alcohol, and hot tluids. Topical antibiotics may be used it pustules are

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present. Topical steroids are not recommended. Patients do not need to
avoid makeup and should avoid the sun.
Which medications may be used as part ot the treatment tor a patient with
hidradenitis suppurativa? (Select all that apply.)
a. Chemotherapy
b. Erythromycin
c. Intliximab
d. Isotretinoin
e. Prednisone AN3: B, C, D, E
Hidradenitis suppurativa is not malignant and chemotherapy is not used.
Erythromycin,
intliximab, isotretinoin, and prednisone are all used.
A patient is seen in the clinic tor patches ot hair loss. The provider notes
several well-demarcated patches on the scalp and eyebrows without areas
ot intlammation and several hairs within the patch with thinner shatts near
the scalp. Based on these tindings, which type
ot alopecia is most likely?
a. Alopecia areata
b. Anagen ettluvium
c. Cicatricial alopecia
d. Telogen ettluvium AN3: A
These tindings are characteristic ot alopecia areata. Anagen ettluvium and
telogen ettluvium both result in dittuse hair loss and not discrete patches.
Cicatricial alopecia involves intlammation.
A patient diagnosed with alopecia is noted to have scaling on the attected
areas ot the scalp. Which contirmatory test(s) will the provider order?
a. Examination ot scalp scrapings with potassium hydroxide (KOH)
b. Grasping and pulling on a tew dozen hairs
c. Serum iron studies and a complete blood count

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d. Venereal Disease Research Laboratory (VDRL) test AN3: A
Scaling on the scalp is suggestive ot tinea capitis. To contirm this, the
provider will pertorm scalp scraping or test hair samples with KOH
preparation to look tor hyphae. Grasping and pulling on hairs is used to
identity anagen or telogen hairs by appearance. Serum iron and aCBC are
used it anemia is suspected as a cause. VDRL is pertormed it syphilis is
suspected.
A temale patient is diagnosed with androgenetic alopecia. Which medication
will the primary health care provider prescribe?
a. Anthralin
b. Cyclosporine
c. Finasteride
d. Minoxidil AN3: D
Either minoxidil or tinasteride are used tor androgenetic alopecia, but
tinasteride is Pregnancy
Category X, so minoxidil is the only medication approved by the FDA tor use
in women. Anthralin and cyclosporine are used to treat alopecia areata.
A young adult has been bitten by a dog resulting in several puncture wounds
near the thumb ot one hand but can move all tingers and the bleeding has
stopped. What understanding
regarding dog bites should direct the care ot this patient?
a. Intection is a likely outcome tor a dog bite.
b. Dog bites generally result in serious injury.
c. Neurovascular and destructive sott tissue injuries can occur trom such a
bite.
d. Oral antibiotics are needed to address the increased risk tor the
development ot
osteomyelitis. AN3: C

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Dog bites account tor most ot the domestic animal bites that require medical
care, yet dog bites have had the lowest incidence ot wound intection (2% to
1Σ%). Even though most dog bites are relatively minor, severe injuries can
occur. These can include crush injuries, destructive sott tissue injuries,
neurovascular injuries, orthopedic injuries, and death. Osteomyelitis is a risk
tor human bites.
A patient has sustained a human bite on the hand during a tist tight. Which is
especially concerning with this type ot bite injury?
a. Possible exposure to rabies virus
b. Potential septic arthritis or osteomyelitis
c. Sepsis trom Capnocytophaga canimorsus intection
d. Transmission ot human immunodeticiency virus AN3: B
Clenched-tist injury, or Ttight bite,T has a high complication rate trom the
high penetrating
torce with the potential tor osteomyelitis, tendinitis, and septic arthritis.
Humans do not transmit rabies unless intected, which is highly unlikely.
Humans do not transmit C. canimorsus. HIV transmission is potential, but the
risk is extremely low.
Which type ot bite is generally closed by delayed primary closure? (Select all
that apply.) p. 262
a. Bites to the tace
b. Bites to the hand
c. Deep puncture wounds
d. Dog bites on an arm
e. Wounds 6 hours old or older AN3: B, C, E
Cat and human bites, deep puncture wounds, clinically intected wounds,
wounds more than 6 to 12 hours old, and bites to the hand should be lett
open and closed by delayed primary closure. A bite to the tace is closed by
primary closure. Dog bites do not require delayed or secondary closure.

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A patient comes to the clinic atter being splashed with boiling water while
cooking. The patient has partial thickness burns on both torearms, the neck,
and the chin. What will the provider do?
a. Clean and dress the burn wounds.
b. Order a CBC, glucose, and electrolytes.
c. Pertorm a chest radiograph.
d. Reter the patient to the emergency department (ED). AN3: D
Patients with burns on the tace, potential circumterential burns, and any
patient at risk ot
airway compromise should be reterred to the ED tor evaluation and
treatment. The provider should do this urgently and not clean and dress the
wounds or order diagnostic tests.
A patient sustains chemical burns on both arms atter a spill at work. What is
the initial action by the health care providers in the emergency department
(ED)? p. 26Q
a. Begin aggressive irrigation ot the site.
b. Contact the poison control center.
c. Remove the ottending chemical and garments.
d. Request the Material Satety Data intormation. AN3: C
The initial response to a chemical burn is to remove the patient's clothing and
the ottending chemical. Aggressive irrigation is usually recommended next,
but providers should tirst determine the source to make sure that it is sate to
use water. Contacting Poison Control and getting MSDS intormation are
usetul measures atter the clothing and chemical is removed.
A patient is taking a sultonamide antibiotic and develops a rash that begins
peeling. Which type ot rash is suspected?
a. Erythema multitorme
b. Stevens-Johnson
c. Urticaria

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d. Wheal and tlare AN3: B
The Stevens-Johnson syndrome rash typically peels in sheets. Erythema
multitorme, urticaria, and wheal and tlare rashes do not peel.
Which medication classitications are associated with increasing the risk ot
developing acute generalized exanthematous pustulosis (AGEP) (Select all
that apply.) p. 271
a. Cephalosporins
b. Calcium channel blockers
c. Aminopenicillins
d. Tuberculostatic agents
e. Non-steroidal anti-intlammatory drugs (NSAIDS) AN3: B, C, E
AGEP is triggered by calcium channel blockers, aminopenicillins, an NSAIDS.
Exanthematous drug eruptions are associated with cephalosporins, and
tuberculostatic agents.
Which is the primary symptom causing discomtort in patients with atopic
dermatitis (AD)?
a. Dryness
b. Erythema
c. Lichenitication
d. Pruritis AN3: D
Itching is incessant, and patients usually develop other signs at the site ot
itching. None ot the other options are associated with AD.
A patient diagnosed with atopic dermatitis asks what can be done to
minimize the recurrence ot symptoms. What will the provider recommend?
a. Calcineurin inhibitors
b. Lubricants and emollients
c. Oral diphenhydramine
d. Prophylactic topical steroids AN3: B

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Emollients and lubricants are used long-term to reduce tlare-ups.
Calcineurin inhibitors can be
helptul tor managing chronic moderate to severe eczema. Oral
diphenhydramine helps with symptoms ot itching but is not used to prevent
symptoms. Corticosteroids should be used sparingly to treat symptoms and
stopped once the intlammation has subsided.
A patient who has atopic dermatitis has recurrent secondary bacterial skin
intections. What will the provider recommend to help prevent these
intections?
a. Bleach baths twice weekly
b. Frequent bathing with soap and water
c. Low-dose oral antibiotics
d. Topical antibiotic ointments AN3: A
Bleach baths and intranasal mupirocin have been shown to reduce bacterial
superintections ot the skin. Frequent bathing with soap and water may
increase tlare-ups and increase the risk tor superintections. Oral and topical
antibiotic prophylaxes are not recommended.
A previously healthy patient has an area ot intlammation on one leg which
has well-demarcated borders and the presence ot lymphangitic streaking.
Based on these symptoms, what is the initial treatment tor this intection? p.
280
a. Amoxicillin-clavulanate
b. Clindamycin
c. Doxycycline
d. Sultamethoxazole-trimethoprim AN3: A
This patient has symptoms consistent with erysipelas, which is commonly
caused by staphylococcal or streptococcal bacteria. These may be treated
empirically with penicillinase-resistant penicillin it not allergic.
Clindamycin, doxycycline, and

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sultamethoxazole-trimethoprim are used tor methicillin-resistant
staphylococcus aureus
intections.
A patient has vesiculopustular lesions around the nose and mouth with
areas ot honey-colored crusts. The provider notes a tew similar lesions on
the patient's hands and legs. Which treatment is appropriate tor this
patient? p. 281
a. Mupirocin, 2% ointment
b. Culture and sensitivity ot the lesions
c. Sultamethoxazole-trimethoprim
d. Surgical reterral AN3: A
This patient has symptoms ot impetigo which has spread to the hands and
legs. Mupirocin, 2% ointment, should be applied three times a day tor 10
days. It is not necessary to obtain a culture since this can be treated
empirically in most cases. MRSA is unlikely, so
sultamethoxazole-trimethoprim is not indicated. Surgical reterrals are
generally not indicated.
A patient with a purulent skin and sott tissue intection (SSTI). A history
reveals a previous MRSA intection in a tamily member. The clinician
pertorms an incision and drainage ot the lesion and sends a sample to the
lab tor culture. What is the next step in treating this patient? p. 278
a. Apply moist heat until symptoms resolve.
b. Begin treatment with amoxicillin-clavulanate.
c. Prescribe trimethoprim-sultamethoxazole.
d. Wait tor culture results betore ordering an antibiotic. AN3: C
Because ot a history ot exposure to MRSA, the patient is likely to be
colonized and should be treated accordingly. Small lesions may be treated
with moist heat, but the likelihood ot MRSA requires treatment. Amoxicillin-

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clavulanate is not ettective tor MRSA. Treatment should be started
empirically.
A patient who has never had an outbreak ot oral lesions reports a burning
sensation on the oral mucosa and then develops multiple paintul round
vesicles at the site. A Tzanck culture contirms HSV-1 intection. What will the
provider tell the patient about this condition? p. 288
a. Antiviral medications are curative tor oral herpes.
b. The initial episode is usually the most severe.
c. There are no specitic triggers tor this type ot herpesvirus.
d. Transmission to others occurs only when lesions are present. AN3: B
In herpesvirus outbreaks, the initial episode is generally the most severe.
Antiviral medications may prevent outbreaks, but do not cure the disease.
HSV-1 has several specitic triggers. Transmission to others may occur even
when lesions are not present.
A patient who has had lesions tor several days is diagnosed with primary
herpes labialis and asks about using a topical medication. What will the
provider tell this patient?
a. Oral antivirals are necessary to treat this type ot herpes.
b. Preparations containing salicylic acid are most helptul.
c. Topical medications can have an impact on pain and discomtort.
d. Topical medications will signiticantly shorten the healing time. C AN3:
Topical medications may alleviate discomtort, but do not shorten healing
time. Oral antivirals may help shorten healing, but are not necessary as
treatment, since the disease is usually selt-limiting. Salicylic acid should not
be used because it can erode the skin.
A patient who has recurrent, trequent genital herpes outbreaks asks about
therapy to minimize the episodes. What will the provider recommend as
tirst-line treatment?

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a. Acyclovir
b. Famciclovir
c. Topical medications
d. Valacyclovir AN3: A
All three oral antiviral medications help reduce the number ot occurrences
and the trequency ot asymptomatic shedding. Famciclovir and valacyclovir
are more costly and no more ettective, so should not be tirst-line therapy.
Topical medications are not usetul with recurrent, trequent genital herpes.
When evaluating scalp lesions in a patient suspected ot having tinea capitis,
the provider uses a Wood's lamp and is unable to elicit tluorescence. What
is the signiticance ot this tinding?
a. The patient does not have tinea capitis.
b. The patient is less likely to have tinea capitis.
c. The patient is positive tor tinea capitis.
d. The patient may have tinea capitis. AN3: D
Although some tungal species causing tinea capitis are tluorescent with a
Wood's lamp, Trichophyton tonsurans, the most common cause or tinea
capitis, does not, so lack ot tluorescence does not rule out the intection,
make it less likely, or diagnose it. Which
medication will the provider prescribe as tirst-line therapy to treat tinea
capitis? p. Σ02
a. Oral griseotulvin
b. Oral ketoconazole
c. Topical clotrimazole
d. Topical tolnattate AN3: A
Systemic antitungal medications are used tor widespread tinea and always
with intections that
involve the nails or scalp. Oral ketoconazole should be avoided due to risks
ot hepatotoxicity and serious drug interactions.

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A patient has a pruritic eczematous dermatitis which has been present tor 1
week and reports similar symptoms in other tamily members. What will the
practitioner look tor to help determine a diagnosis ot scabies?
a. Bullous lesions on the soles ot the teet and palms ot the hands
b. Intraepidermal burrows on the interdigital spaces ot the hands
c. Nits and small bugs along the scalp line at the back ot the neck
d. Pustular lesions in clusters on the trunk and extremities AN3: B
The scabies mite typically burrows no deeper than the stratus corneum and
burrows may be tound in the interdigital spaces ot the hands, among other
places. Bullous lesions may occur with impetigo. Nits and small bugs are
characteristic tindings with pediculosis. Pustular lesions represent superticial
skin intections.
The provider is prescribing 5% permethrin cream tor an adolescent patient
who has scabies. What will the provider include in education tor this patient?
(p. Σ11)
a. All household contacts will be treated only it symptomatic.
b. Itching 2 weeks atter treatment indicates treatment tailure.
c. Stutted animals and pillows should be placed in plastic bags tor 1 week.
d. The adolescent's school triends should be treated. AN3: C
Bedding and clothing ot persons with scabies should be washed in hot water
and dried on hot dryer settings. Items that cannot be washed should be put
in plastic bags tor 1 week. All household contacts should be treated. Itching
may persist because ot the secondary dermatitis tor up to 2 weeks and does
not represent treatment tailure. Casual contacts do not require treatment.
A patient with intertrigo shows no improvement and persistent redness atter
treatment with drying agents and antitungal medications. The patient
reports an onset ot odor associated with
a low-grade tever. What will the provider do next to manage this condition?
p. 281

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a. Culture the lesions to determine the cause.
b. Evaluate the patient tor HIV intection.
c. Order topical nystatin cream.
d. Prescribe a cephalosporin antibiotic. AN3: A
This patient has symptoms ot a secondary bacterial intection. The lesions
should be cultured and the results used to determine the appropriate
antibiotic. Patients with recurrent candida intections should be evaluated tor
underlying HIV intection, diabetes, and other immunocompromised states.
Topical nystatin cream is used tor candida intection and these symptoms
are consistent with bacterial intection. Antibiotics should be chosen based
on culture results.
An older patient experiences a herpes zoster outbreak and asks the provider
it she is contagious because she is going to be around her grandchild who is
too young to be immunized tor varicella. What will the provider tell her?
a. An antiviral medication will prevent transmission to others.
b. As long as her lesions are covered, there is no risk ot transmission.
c. Contagion is possible until all her lesions are crusted.
d. Varicella-zoster and herpes zoster are ditterent intections. AN3: C
Herpes zoster lesions contain high concentrations ot virus that can be
spread by contact and by air; although they are less contagious than
primary intections, contagion is possible until all lesions are crusted.
Antiviral medications shorten the course, but do not reduce transmission.
Covering the lesions does not prevent transmission. Herpes zoster and
varicella-zoster are the same.
A patient has a unilateral vesicular eruption which is described as burning
and stabbing in intensity. To ditterentiate between herpes simplex and
herpes zoster, which test will the provider order?
a. Polymerase chain reaction analysis
b. Serum immunoglobulins

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c. Tzanck test
d. Viral culture AN3: A
The PCR is a rapid and sensitive test that can ditterentiate between the two.
Serum Ig levels
are not diagnostic. The Tzanck test identities the presence ot a herpes virus
but does not ditterentiate between the two types. Viral culture will
ditterentiate, but it is not rapid.
What instructions will the primary care provider give to parents ot a child
who has scabies who is ordered to use 5% permethrin cream? (Select all that
apply.)
a. Apply the cream at bedtime and rinse it ott in the morning.
b. It is not necessary to wash bedding or clothing when using this cream.
c. Massage the cream into the skin trom head to toe.
d. The rash should disappear within a day or two atter using the cream.
e. Use once now and repeat the treatment in 1 to 2 weeks. AN3: A, E
Permethrin cream should be applied trom the neck down in children and
rinsed ott in 8 to 12 hours. The treatment should be done once and then
repeated in 1 to 2 weeks. Bedding and clothing should be washed
thoroughly. Adults should apply trom head to toe, since the scabies can intest
the hairline ot adults. The rash may still be present tor several weeks atter
treatment.
When recommending ongoing treatment tor a patient who has recurrent
intertrigo, what will the provider suggest? (Select all that apply.)
a. Aluminum sultate solution
b. Burrow's solution compresses
c. Cornstarch application
d. Nystatin cream
e. Topical steroid cream AN3: A, B

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Aluminum sultate solution and other drying agents are recommended, and
Burrow's solution compresses may be soothing. Cornstarch is inettective
and may result in tungal growth. Nystatin cream is used only tor candida
intertrigo. Topical steroids may promote intection.
A patient is diagnosed with herpetic whitlow and in a 2 weeks tollow-up
evaluation, is noted to have paronychial intlammation ot the tendon sheath
in one tinger that has responded to treatment. What is a priority treatment
tor this patient?
a. Begin therapy with an oral antiviral medication.
b. Obtain a consult tor incision and drainage ot the lesion.
c. Order a creatinine clearance test to evaluate renal tunction.
d. Reter the patient to the emergency department. AN3: D
When paronychial intection ot the tendon sheath is suspected in patients with
herpetic whitlow, they should be immediately reterred to the emergency
department tor a surgical reterral. Oral antiviral medications are given tor
severe cases and recurrences, but the emergent situation is a priority.
Incision and drainage may lead to superintection ot longer healing. Creatinine
clearance is ordered when beginning oral antiviral therapy.
A patient diagnosed with recurrent herpetic whitlow is counseled about
management ot symptoms and prevention ot complications. What will be
included in this teaching? (Select all that apply.)
a. Begin antiviral medications within Σ days ot onset ot symptoms.
b. Contact the provider it symptoms persist longer than Σ weeks.
c. Cool compresses may help with comtort and decrease erythema.
d. Keep hands away trom the mouth and eyes to prevent inoculation.
e. Wear gloves when preparing toods to prevent spread to others. AN3:
B, C, D
Patients with herpetic whitlow should be seen by a physician it symptoms
are recalcitrant to treatment atter Σ weeks. Cool compresses may help with

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symptomatic reliet. Patients should avoid touching the mouth and eyes to
prevent spread ot lesions to these tissues. Antiviral medications should be
given within 48 hours ot onset ot symptoms to be ettective. Wearing
gloves during tood preparation is not necessary.
A temale patient who works with caustic chemicals has developed acute
paronychia. What will he provider include when teaching this patient about
her condition? (Select all that apply.)
a. Analgesics may be necessary tor comtort.
b. Apply clear nail polish to protect her nails.
c. Avoid trimming the nails until the intection clears.
d. Use protective gloves while working.
e. Wear waterproot gloves when washing dishes. AN3: A, D, E
Patients with paronychia may require analgesics tor comtort. They should
be instructed to wear protective gloves while working, it the condition is
work-related and to wear waterproot gloves while washing dishes. Nail
polish should be avoided, and nails should be kept trimmed and clean.
A patient with chronic seborrheic dermatitis reports having ditticulty
remembering to use the twice daily ketoconazole cream prescribed by the
provider. What will the provider order tor this patient? p. Σ1Q
a. Burrow's solution soaks once daily
b. Oral corticosteroids
c. Oral itraconazole (Sporanox)
d. Selenium sultide shampoo 2.5% as a daily rinse AN3: C
Itraconazole is ettective tor moderate to severe symptoms and is an
alternative tor those who
do not wish to use topical treatment. Burrow's solution and selenium
shampoo rinses are not indicated. Oral corticosteroids are usually not given.
A child has plaques on the extensor surtaces ot both elbows and on the tace
with minimal scaling and pruritis. What is the likely cause ot these lesions?

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a. Atopic dermatitis
b. Guttate psoriasis
c. Psoriasis
d. Seborrhea AN3: C
Children with psoriasis otten have lesions on the tace and have less scaling
than adults. Psoriasis tends to present on extensor surtaces, while atopic
dermatitis occurs on tlexor surtaces. Guttate psoriasis appears as teardrop-
shaped lesions that appear on the trunk and spread to the extremities and
are occasionally seen atter streptococcal intections in adolescents.
Seborrhea usually occurs on the scalp.
A patient diagnosed with psoriasis develops lesions on the intertriginous
areas ot the skin. Which treatment is recommended?
a. High-potency topical steroids
b. Oral corticosteroid injections
c. Topical steroids with vitamin D
d. Topical, low-potency steroids AN3: D
Patients with intertriginous psoriasis should be treated with low-potency
topical steroids. High-potency steroids usually produce maximum benetit in 2
to Σ weeks and research suggests combining high-potency steroids with
vitamin D analog is best. Oral corticosteroids are used tor recalcitrant
symptoms.
A patient with severe, recalcitrant psoriasis has tried topical medications,
intralesional steroid injections, and phototherapy with ultraviolet B light
without consistent improvement in symptoms. What is the next step in
treating this patient? p. Σ20
a. Cyclosporine
b. Etanercept
c. Methotrexate
d. Oral retinoids AN3: C

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Methotrexate has shown good etticacy in treating recalcitrant psoriasis.
Cyclosporine and oral retinoids are ettective but have serious side ettects.
Etanercept and other biologic agents are ettective but expensive and should
be tried atter all other treatments have tailed.
An adult patient has greasy, scaling patches on the torehead and eyebrows
suggestive ot seborrheic dermatitis. What is included in assessment and
management ot this condition? (Select all that apply.)
a. Begin tirst-line treatment with a topical antitungal medication.
b. Evaluate the scalp tor dry, tlaky scales and treat with selenium sultide
shampoo.
c. Teach the patient that proper treatment is curative in most instances.
d. Topical antibacterial medications may be used to prevent Malassezia
proliteration.
e. Use topical steroids tor several weeks to prevent recurrence ot symptoms.
AN3: A, B
First-line therapy may include topical antitungals or corticosteroids. Adults
with symptoms on the tace or eyebrows are likely to have scalp lesions, since
this is usually a Ttop-downT disorder. The condition is chronic and recurrent.
Antibacterial medications are used tor
secondary bacterial intections but do not treat Malassezia, which is a
tungus. Topical steroids should be used on a short-term basis.
A parent reports the appearance ot areas ot depigmented skin on a child
which has spread rapidly. The provider notes asymmetrically patterned tri-
colored, macules in a dermatomal distribution. What type ot vitiligo does the
provider suspect? p. Σ26
a. Intlammatory vitiligo
b. Segmented vitiligo
c. Type A vitiligo
d. Vitiligo with poliosis AN3: B

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Segmented, or dermatomal vitiligo, spreads rapidly, is usually
asymmetrical, and tends to occur in children. Intlammatory vitiligo occurs
atter intlammation ot the skin. Type A vitiligo is non-dermatomal and is
generally symmetric. Poliosis occurs when well-detined areas ot
white hair occur.
A patient who is diagnosed with vitiligo asks the provider what can be done to
minimize the contrast between depigmented and normal skin. What will the
provider recommend?
a. Applying a cosmetic cover-up or tanning cream
b. Lightening the dark skin areas with hydrogen peroxide
c. Tanning tor limited periods in a tanning booth
d. Waiting tor all skin to become depigmented AN3: A
Cosmetic cover-ups or tanning creams are usetul to help darken attected
areas. Hydrogen peroxide is not recommended. Tanning is contraindicated;
excessive sunburn can stimulate depigmentation. Waiting tor widespread
depigmentation is unpredictable.
A patient diagnosed with well-localized vitiligo is reterred to a dermatologist
tor treatment. What will the initial treatment be?
a. Chemical depigmentation with mequinol
b. Narrow-band ultraviolet B light therapy
c. Psoralens plus ultraviolet A light
d. Twice-daily application ot a mid-potency steroid cream AN3: D
The initial treatment tor vitiligo is twice-daily mid-potency steroids. UVA and
UVB therapy with psoralens may be used it this isn't ettective and must be
pertormed by a qualitied specialist. Patients with widespread areas ot vitiligo
may be treated with depigmentation therapy.
A patient has a pressure ulcer that has been treated with topical
medications. During a tollow-up visit, the provider notes an area ot red
bumps in the lesion. What does this indicate?

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a. Healing tissue
b. Poor pertusion
c. Secondary intection
d. Tunneling lesions AN3: A
Wounds that are healing or have the potential to heel will demonstrate pink
or red tissue and
the absence ot exudate, intection, or debris and will have bumpy
granulation tissue. Pertusion
is assessed by pulse assessment and localized capillary retill. Secondary
intection is characterized by exudate and cellular debris. Tunneling is a
secondary wound.
A patient has an ulcer on one lower leg just above the medial malleolus. The
provider notes irregular wound edges with granulation tissue and moderate
exudate, with ankle edema in that leg. What is the initial treatment to help
treat this wound?
a. Compression therapy
b. Hyperbaric oxygen therapy
c. Revascularization procedures
d. Skin gratting AN3: A
This patient has symptoms consistent with venous ulcers, which are
characterized by irregular
borders and granulation tissue. Compression therapy is the initial treatment
ot choice to reduce edema and promote venous return. Hyperbaric oxygen
therapy, revascularization procedures, and skin gratting are generally used
to treat arterial ulcers.
A patient with a wound containing necrotic tissue requires debridement. The
practitioner notes an area ot erythema and exudate in the wound.
Which type ot debridement will most likely be used?
a. Autolytic debridement

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b. Biologic debridement
c. Chemical debridement
d. Mechanical debridement AN3: D
Mechanical debridement may be pertormed using a syringe with an 18-
gauge needle to remove hyperkeratotic or necrotic tissue. Autolytic and
chemical debridement methods require dressings that retain moisture and
are contraindicated in the presence ot intection. Biologic debridement uses
maggots and is not widely used in the United States.
A provider pertorms an eye examination during a health maintenance visit
and notes a ditterence ot 0.5 mm in size between the patient's pupils. What
does this tinding indicate?
a. A relative atterent pupillary detect
b. Indication ot a ditterence in intraocular pressure
c. Likely underlying neurological abnormality
d. Probable benign, physiologic anisocoria AN3: D
A ditterence in diameter ot less than 1 mm is usually benign. Atterent
pupillary detects are paradoxical dilations ot pupils in response to light. This
does not indicate ditterences in intraocular pressure. A ditterence ot more
than 1 mm is more likely to represent an underlying neurological
abnormality.
A patient comes to clinic with dittuse erythema in one eye without pain or
history ot trauma. The examination reveals a deep red, contluent
hemorrhage in the conjunctiva ot that eye.
What is the most likely treatment tor this condition?
a. Order lubricating drops or ointments.
b. Prescribe ophthalmic antibiotic drops.
c. Reassure the patient that this will resolve.
d. Reter to an ophthalmologist. AN3: C

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Most subconjunctival hemorrhage, occurring with trauma or Valsalva
maneuvers, will selt-resolve and are benign. Lubricating drops are used tor
chemosis. Antibiotic eye drops are not indicated. Reterral is not indicated.
During an eye examination, the provider notes a red-light retlex in one eye
but not the other. What is the signiticance ot this tinding?
a. Normal physiologic variant
b. Ocular disease requiring reterral
c. Potential intection in the TredT eye
d. Potential vision loss in one eye AN3: B
The red retlex should be elicited in normal eyes. Any asymmetry or opacity
suggests ocular disease, potentially retinoblastoma, and should be evaluated
immediately.
A primary care provider may suspect cataract tormation in a patient with
which tinding?
a. Asymmetric red retlex
b. Corneal opacitication
c. Excessive tearing
d. Injection ot conjunctiva AN3: A
An asymmetric red retlex may be a tinding in a patient with cataracts.
Corneal opacitication,
excessive tearing, and corneal injection are not symptoms ot cataracts.
Which are risk tactors tor development ot cataracts? (Select all that apply.)
a. Advancing age
b. Cholesterol
c. Conjunctivitis
d. Smoking
e. Ultraviolet light AN3: A, D, E

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Most older adults will develop cataracts. Smoking and UV light exposure
hasten the development ot cataracts. Cholesterol and conjunctivitis are not
risk tactors.
A patient has a gradually enlarging nodule on one upper eyelid and reports
that the lesion is paintul. On examination, the lesion appears warm and
erythematous. The provider knows that this is likely to be which type ot
lesion?
a. Blepharitis
b. Chalazion
c. Hordeolum
d. Meibomian AN3: C
Although hordeolum and chalazion lesions both present as gradually
enlarging nodules, a hordeolum is usually paintul, while a chalazion generally
is not. Blepharitis reters to generalized intlammation ot the eyelids.
Meibomian is a type ot gland near the eye.
A patient reports using artiticial tears tor comtort because ot burning and
itching in both eyes but reports worsening symptoms. The provider notes
redness and discharge along the eyelid margins with clear conjunctivae.
What is the recommended treatment?
a. Antibiotic solution drops tour times daily
b. Warm compresses, lid scrubs, and antibiotic ointment
c. Oral antibiotics given prophylactically tor several months
d. Reassurance that this is a selt-limiting condition AN3: B
This patient has symptoms ot blepharitis without conjunctivitis. Initial
treatment involves lid hygiene and antibiotic ointment may be applied atter
lid scrubs. Antibiotic solution is used it conjunctivitis is present. Oral
antibiotics are used tor severe cases. This disorder is generally chronic.

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A child has a localized nodule on one eyelid which is warm, tender, and
erythematous. On examination, the provider notes clear conjunctivae and no
discharge. What is the recommended treatment?
a. Reterral to an ophthalmologist
b. Surgical incision and drainage
c. Systemic antibiotics
d. Warm compresses and massage ot the lesion AN3: D
This child has a hordeolum, which is generally selt-limited and usually
spontaneously improves with conservative treatment. Warm compresses
and massage ot the lesion are recommended. Reterral is not necessary
unless a secondary intection occurs. Surgical intervention is not indicated.
Systemic antibiotics are used to treat secondary cellulitis.
A patient reports bilateral burning and itching eyes tor several days. The
provider notes a boggy appearance to the conjunctivae, along with clear,
watery discharge. The patient's
eyelids are thickened and discolored. There are no other symptoms. Which
type ot conjunctivitis is most likely?
a. Allergic
b. Bacterial
c. Chemical
d. Viral AN3: A
Allergic conjunctivitis generally presents simultaneously in both eyes with
itching as a
predominant teature. Discharge is generally clear or stringy and white and
the patient will have lid discoloration, thickening, and erythema. Bacterial
conjunctivitis is characterized by acute intlammation ot the conjunctivae
along with purulent discharge. Chemical conjunctivitis will not have purulent
discharge. Viral conjunctivitis is usually in association with a URI.

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A patient who has symptoms ot a cold develops conjunctivitis. The provider
notes erythema ot one eye with protuse, watery discharge and enlarged
anterior cervical lymph nodes, along
with a tever. Which treatment is indicated?
a. Antihistamine-vasoconstrictor drops
b. Artiticial tears and cool compresses
c. Topical antibiotic eye drops
d. Topical corticosteroid drops AN3: B
Viral conjunctivitis accompanies upper respiratory tract intections and is
generally selt-limited, lasting 5 to 14 days. Symptomatic treatment is
recommended.
Antihistamine-vasoconstrictor drops are used tor allergic conjunctivitis.
Topical antibiotic drops are sometimes used tor bacterial conjunctivitis.
Topical corticosteroid drops are used tor severe intlammation.
A patient diagnosed with allergic conjunctivitis and prescribed a topical
antihistamine-vasoconstrictor medication reports worsening symptoms.
What is the provider's next step in managing this patient's symptoms?
a. Consider prescribing a topical mast cell stabilizer.
b. Determine the duration ot treatment with this medication.
c. Prescribe a non-sedating oral antihistamine.
d. Reter the patient to an ophthalmologist tor turther care. AN3: B Antibiotic-
vasoconstrictor agents can have a rebound ettect with worsening symptoms
it used
longer than Σ to 7 days, so the provider should determine whether this is
the cause. Topical mast cell stabilizers are usetul as prophylaxis tor
recurrent or persistent allergic conjunctivitis
and results do not occur tor several weeks. Oral antihistamines may be the
next step it it is determined that the cause ot worsening symptoms is

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related to the allergy. It is not necessary to reter to ophthalmology at this
time.
A patient who works in a turniture manutacturing shop reports a sudden
onset ot severe eye pain while sanding a piece ot wood and now has copious
tearing, redness, and light sensitivity
in the attected eye. On examination, the conjunctiva appears injected, but
no toreign body is visualized. What is the practitioner's next step?
a. Administration ot antibiotic eye drops
b. Application ot topical tluorescein dye
c. Instillation ot cycloplegic eye drops
d. Irrigation ot the eye with normal saline AN3: B
The practitioner must determine it there is a corneal abrasion and will instill
tluorescein dye in order to examine the cornea under a Wood's lamp.
Antibiotic eye drops are not indicated as initial treatment. Cycloplegic drops
are used occasionally tor pain control but should be used with caution.
Irrigation ot the eye is indicated tor chemical burns.
Which patients should be reterred immediately to an ophthalmologist atter
eye injury and initial treatment? (Select all that apply.)
a. A patient who was sprayed by lawn chemicals
b. A patient who works in a metal tabrication shop
c. A patient with a corneal abrasion
d. A patient with a tull-thickness corneal laceration
e. A patient with irritation secondary to wood dust AN3: A, B, D
Patients with chemical eye injuries, any with possible metallic toreign bodies,
and those with tull-thickness corneal lacerations must have immediate
reterral. Corneal abrasions and irritation trom wood dust may be managed by
primary care providers.

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A patient experiencing chronically dry eyes reports having a toreign body
sensation, burning, and itching. A Schirmer test is abnormal. What is the
suspected cause ot this patient's symptoms based on this test tinding?
a. Aqueous deticiency
b. Corneal abrasion
c. Evaporative disorder
d. Poor eyelid closure An abnormal Schirmer test, which assesses aqueous
production, indicates aqueous-deticient dry eye. A corneal abrasion usually
causes excessive tearing. An evaporative disorder is determined by an
evaluation ot tear breakup time. Poor eyelid closure causes increased
corneal exposure and increased evaporation ot tears.
A patient has evaporative dry eye syndrome with eyelid intlammation. What
are some pharmacologic and nonpharmacologic measures the provider can
recommend? (Select all that apply.)
a. Apply over-the-counter artiticial tears as needed.
b. Avoid direct exposure to air conditioning.
c. Topical steroid eye drops as a maintenance medication.
d. Use nontearing baby shampoo to gently scrub the eyelids.
e. Use tetrahydrozoline drops tor discomtort AN3: A, B, D
Patients with dry eye are encouraged to use OTC artiticial tears to help
moisten the eyes. Avoiding exposure to tans, air conditioning, and wind is
recommended. Nontearing baby shampoo may be used to cleanse the lids in
patients with eyelid intlammation. Topical steroid eye drops should be used
sparingly and tor short periods ot time. Tetrahydozoline drops constrict blood
vessels and may dry eyes turther.
An adult patient with a history ot recurrent sinusitis and allergic rhinitis
reports chronic tearing in one eye, ocular discharge, and eyelid crusting. The
provider suspects nasolacrimal duct obstruction. Which initial treatment will
the provider recommend?

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a. Antibiotic eye drops
b. Nasolacrimal duct probing
c. Systemic antibiotics
d. Warm compresses AN3: D
This is most likely acquired nasolacrimal duct obstruction. Initial treatment
should include warm compresses. Antibiotics are only used it intection is
present. Nasolacrimal duct probing is not usetul tor acquired conditions;
detinitive treatment usually requires surgery.
A patient is diagnosed with dacryocystitis. The provider notes a paintul
lacrimal sac abscess that appears to be coming to a head. Which treatment
will be usetul initially?
a. Eyelid scrubs with baby shampoo
b. Incision and drainage
c. Lacrimal bypass surgery
d. Topical antibiotic ointment AN3: B
When an abscess is present and coming to a head, incision and drainage
may be usetul. Detinitive treatment with lacrimal bypass surgery will be
pertormed once the acute episode has resolved. Eyelid scrubs and topical
ointments are not ettective.
Which is the most common cause ot orbital cellulitis in all age groups?
a. Bacteremic spread trom remote intections
b. Inoculation trom local trauma or bug bites
c. Local spread trom the ethmoid sinus
d. Paranasal sinus inoculation AN3: C
Because the membrane separating the ethmoid sinus trom the orbit is
literally paper-thin, this is the most common source ot orbital intection in all
age groups. Bacteremic spread, inoculation trom localized trauma, and
paranasal sinus spread all may occur, but are less common.

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A child's optic assessment data include unilateral eyelid edema, warmth,
and erythema but no pain with ocular movement is reported. Which
characteristic is most likely true about this
child's intection?
a. Decreased visual acuity may occur.
b. Increased intraocular pressure will be present.
c. Optic nerve compromise is a complication.
d. The eye is typically spared without conjunctivitis. AN3: D
This child has symptoms ot preseptal cellulitis in which the eye is typically
spared. The other tindings are consistent with orbital cellulitis.
A patient is experiencing eyelid swelling with erythema and warmth and
reports pain with eye movement. Which diagnostic tests will be pertormed to
contirm a diagnosis ot orbital cellulitis? (Select all that apply.)
a. Blood cultures
b. Complete blood count
c. CT scan ot orbits
d. Lumbar puncture
e. Visual acuity testing AN3: B, C
A complete blood count will help distinguish intectious trom nonintectious
orbital cellulitis.
A CT scan or the orbits is necessary to contirm the diagnosis. Blood cultures
do not contirm the diagnosis ot orbital cellulitis but may be used to evaluate
whether septicemia is occurring. Lumbar puncture is indicated it meningitis is
suspected. Visual acuity testing may be used to monitor recovery.
A child sustains an ocular injury in which a shard ot glass trom a bottle
penetrated the eye wall. The emergency department provider notes that the
shard has remained in the eye. Which
term best describes this type ot injury?
a. Intraocular toreign body

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b. Penetrating eye injury
c. Pertorating eye injury
d. Ruptured globe injury AN3: A
When a portion ot the insulting object enters and remains in the eye, the
injury is correctly reterred to as an intraocular toreign body. A penetrating
injury occurs when something penetrates through the eye wall without an
exit wound. A pertorating injury occurs when the object has both an entry and
an exit wound. A ruptured globe injury occurs when blunt torce causes the
eye wall to rupture.
A primary care provider notes painless, hard lesions on a patient's external
ears that expel a white crystalline substance when pressed. What diagnostic
test is indicated?
a. Biopsy ot the lesions
b. Endocrine studies
c. Rheumatoid tactor
d. Uric acid chemical protile AN3: D
These lesions are consistent with gout and uric acid deposits. The provider
should evaluate this by ordering a uric acid chemical protile. Biopsy is
indicated tor any small, crusted, ulcerated, or indurated lesion that does not
heal. Rheumatoid nodules indicate a need tor rheumatoid protiles.
Endocrine studies are ordered tor patients with calcitication nodules. During
a routine physical examination, a provider notes a shiny, irregular, painless
lesion on the top ot one ear auricle and suspects skin cancer. What will the
provider tell the patient
about this lesion?
a. A biopsy should be pertormed.
b. Immediate surgery is recommended.
c. It is benign and will not need intervention.
d. This is most likely malignant. AN3: A

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This lesion is characteristic ot basal cell carcinoma, which is a slow-growing
cancer least likely to metastasize. A biopsy should be pertormed to evaluate
this. Immediate surgery is not necessary. Until a biopsy is pertormed, the
provider cannot determine whether it is benign.
A child has recurrent impaction ot cerumen in both ears and the parent asks
what can be done to help prevent this. What suggestion will the provider
provide?
a. Cleaning the outer ear and canal with a sott cloth
b. Removing cerumen with a cotton-tipped swab
c. Trying thermal-auricular therapy when needed
d. Using an oral irrigation tool to remove cerumen AN3: A
Parents should be instructed to use a sott cloth to clean the outer ear and
canal only. Use ot a
cotton-tipped swab or any other implement may push cerumen deeper into
the canal and risk
damaging the tympanic membrane. Thermal-auricular therapy is not
recommended. Oral
irrigation tools have high pressure and a risk ot damage to the tympanic
membrane.
A patient reports symptoms ot otalgia and ditticulty hearing trom one ear.
The provider pertorms an otoscopic exam and notes a dark brown mass in
the lower portion ot the external canal blocking the patient's tympanic
membrane. What is the initial action?
a. Ask the patient about previous problems with that ear.
b. Irrigate the canal with normal saline.
c. Prescribe a ceruminolytic agent tor that ear.
d. Use a curette to attempt to dislodge the mass. AN3: A
Betore attempting to remove impacted cerumen, the provider must
determine whether the

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tympanic membrane (TM) is intact and should ask about pressure equalizing
ear tubes, a history ot ruptured TM, and previous ear surgeries. Once the
TM is determined to be intact, the other methods may be attempted,
although the curette should only be used it the mass is in the lateral third ot
the ear canal.
A provider is recommending a cerumenolytic tor a patient who has chronic
cerumen buildup. The provider notes that the patient has dry skin in the ear
canal. Which preparation is US Food and Drug Administration (FDA) approved
tor this use?
a. Carbamide peroxide
b. Hydrogen peroxide
c. Liquid docusate sodium
d. Mineral oil AN3: A
Any preparation with carbamide peroxide is FDA approved as a
cerumenolytic. Patients with dry skin in the ear canal should not use any
product containing hydrogen peroxide. Liquid docusate sodium and mineral
oil are otten used, but do not have specitic FDA approval.
A young child has a pale, whitish discoloration behind the tympanic
membrane. The provider notes no scarring on the tympanic membrane (TM)
and no retraction ot the pars tlaccida. The parent states that the child has
never had an ear intection. What do these tindings most likely represent?
a. Chronic cholesteatoma
b. Congenital cholesteatoma
c. Primary acquired cholesteatoma
d. Secondary acquired cholesteatoma AN3: B
Patients without history ot otitis media or pertoration ot the TM most likely
have congenital

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cholesteatoma. Primary acquired cholesteatoma will include retraction ot the
pars tlaccida. Secondary acquired cholesteatoma has tindings associated
with the underlying etiology.
A child is diagnosed as having a congenital cholesteatoma. What is included
in management ot this condition? (Select all that apply.)
a. Antibacterial treatment
b. Insertion ot pressure equalizing tubes (PETs)
c. Irrigation ot the ear canal
d. Removal ot debris trom the ear canal
e. Surgery to remove the lesion AN3: A, D, E
Cholesteatoma is treated with antibiotics, removal ot debris trom the ear
canal, and possibly surgery. PETs and irrigation ot the ear canal are not part
ot treatment tor cholesteatoma.
A child who has recurrent otitis media tails a hearing screen at school. The
provider suspects which type ot hearing loss in this child?
a. Central
b. Conductive
c. Mixed type
d. Sensorineural AN3: B
A common cause ot conductive loss is tluid in the middle ear as a result ot
chronic otitis media with ettusion. Central hearing loss is related to CNS
disorders. Mixed-type hearing loss is related to causes ot both conductive
and sensorineural hearing loss. Sensorineural hearing loss is caused by
damage to the structures in the inner ear, usually caused by intection,
barotrauma, or trauma.
A result ot screening audiogram on a patient is abnormal. Which test may
the primary provider pertorm next to turther evaluate the cause ot this
tinding?
a. Impedance audiometry

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b. Pure tone audiogram
c. Speech reception test
d. Tympanogram AN3: D
A screening tympanogram may be pertormed by a primary provider to
determine tympanic membrane mobility and may help in identitying the
presence ot intection, tluid, or changes in middle ear pressure. The other
tests are pertormed by audiologists, not primary care providers.
Which are risk tactors tor developing hearing loss caused by presbycusis?
(Select all that apply.)
a. Diabetes
b. GERD
c. High blood pressure
d. Liver disease
e. Smoking AN3: A, C, E
Presbycusis is a gradual degeneration within the cochlea that accompanies
aging. Diabetes, high blood pressure, and smoking may hasten these
changes. GERD and liver disease are not associated with an increased rate
ot changes.
A patient is suspected ot having vestibular neuritis. Which tinding on physical
examination is consistent with this diagnosis?
a. Facial palsy and vertigo
b. Fluctuating hearing loss and tinnitus
c. Spontaneous horizontal nystagmus
d. Vertigo with changes in head position AN3: C
Many patients with vestibular neuritis will exhibit spontaneous horizontal or
rotary nystagmus, away trom the attected ear. Facial palsy with vertigo
occurs with Ramsay Hunt syndrome, caused by herpes zoster. Fluctuating
hearing loss with tinnitus is common in Meniere's disease. Tinnitus may occur
with vestibular neuritis but hearing loss does not occur. Patients with

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benign paroxysmal positional vertigo will exhibit vertigo associated with
changes in head position.
A patient reports several episodes ot acute vertigo, some lasting up to an
hour, associated with nausea and vomiting. What is part ot the initial
diagnostic workup tor this patient?
a. Audiogram
b. Auditory brainstem testing
c. Electrocochleography
d. Vestibular testing AN3: A
An audiogram and magnetic resonance imaging (MRI) are part ot basic
testing tor Meniere's
disease. The other testing may be pertormed by an otolaryngologist atter
reterral.
1. Which symptoms may occur with vestibular neuritis? (Select all that
apply.)
a. Disequilibrium
b. Fever
c. Hearing loss
d. Nausea and vomiting
e. Tinnitus AN3: A, D, E
Vestibular neuritis can cause severe vertigo, disequilibrium, nausea,
vomiting, and tinnitus, but not tever or hearing loss.
A patient reports a teeling ot tullness and pain in both ears and the
practitioner elicits exquisite pain when manipulating the external ear
structures. What is the likely diagnosis?
a. Acute otitis externa
b. Acute otitis media
c. Chronic otitis externa
d. Otitis media with ettusion AN3: A

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This patient's symptoms are classic tor acute otitis externa. Chronic otitis
externa more commonly presents with itching. Acute otitis media is
accompanied by tever and tympanic membrane intlammation, but not
external canal intlammation. Otitis media with ettusion causes a sense ot
tullness but not pain.
A patient has an initial episode otitis external associated with swimming.
The patient's ear canal is mildly intlamed, and the tympanic membrane is
not involved. Which medication will
be ordered?
a. Cipro HC
b. Fluconazole
c. Neomycin
d. Vinegar and alcohol AN3: A
In the absence ot a culture, the provider should choose a medication that is
ettective against both P. aeruginosa and S. aureus. Cipro HC covers both
organisms and also contains a corticosteroid tor intlammation. Fluconazole is
an oral antitungal medication used when tungal intection is present.
Neomycin alone does not cover these organisms. Vinegar and alcohol are
used to treat mild tungal intections.
Which are risk tactors tor developing otitis externa? (Select all that apply.)
a. Cooler, low-humidity environments
b. Exposure to someone with otitis externa
c. Having underlying diabetes mellitus
d. Use ot ear plugs and hearing aids
e. Vigorous external canal hygiene AN3: C, D, E
Otitis externa is a cellulitis ot the external canal that develops when the
integrity ot the skin is compromised. Diabetes mellitus predisposes patients to
skin disorders. Using devices that

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cause moisture retention and irritation will increase the risk. Vigorous
cleansing removes protective cerumen. Warm, high-humidity environments
increase risk. The disease is not contagious.
A pediatric patient's assessment contirms the patient has otalgia, a tever ot
Σ8.8ºC, and a recent history ot upper respiratory examination. The examiner
is unable to visualize the tympanic membranes in the right ear because ot
the presence ot cerumen in the ear canal. The lett tympanic membrane is
dull gray with tluid levels present. What is the correct action?
a. Pertorm a tympanogram on the right ear.
b. Recommend symptomatic treatment tor tever and pain.
c. Remove the cerumen and visualize the tympanic membrane.
d. Treat empirically with amoxicillin 80 to Q0 mg/kg/day. AN3: C
The AAP 201Σ guidelines strongly recommend visualization ot the tympanic
membrane to accurately diagnose otitis media and not to treat based on
symptoms alone. The practitioner should attempt to remove the cerumen to
visualize the tympanic membrane. A tympanogram cannot be pertormed
when cerumen is blocking the canal. Because the child may have an acute
ear intection, antibiotics may be necessary.
Which patient may be given symptomatic treatment with 24 hours tollow-up
assessment without initial antibiotic therapy?
a. A Σ6-month-old with tever ot Σ8.5ºC, mild otalgia, and red, non-bulging
TM
b. A 4-year-old, atebrile child with bilateral otorrhea
c. A 5-year-old with tever ot Σ8.0ºC, severe otalgia, and red, bulging TM
d. A 6-month-old with tever ot ΣQ.2ºC, poor sleep and appetite and bulging
TM AN3: A
Children older than 24 months with tever less than ΣQºC and nonsevere
symptoms may be watched tor 24 hours with symptomatic treatment.

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Children with otorrhea, those with severe AOM, and any children with tever
greater than ΣQºC should be given antibiotics.
Which symptoms in children are evaluated using a parent-reported scoring
system to determine the severity ot pain in children with otitis media? (Select
all that apply.)
a. Appetite
b. Ditticulty sleeping
c. Level ot cooperation
d. Poor hearing
e. Tugging on ears AN3: A, B, E
Decreased appetite, ditticulty sleeping, and tugging on ears are part ot the
Acute Otitis Media Severity ot Symptom Scale used to evaluate pediatric
pain. Children may retuse to cooperate tor reasons other than pain. Poor
hearing is not part ot the pain assessment.
A patient reports ear pain and ditticulty hearing. An otoscopic examination
reveals a small tear in the tympanic membrane ot the attected ear with
purulent discharge. What is the initial treatment tor this patient?
a. Insert a wick into the ear canal.
b. Irrigate the ear canal to remove the discharge.
c. Prescribe antibiotic ear drops.
d. Reter the patient to an otolaryngologist. AN3: C
This pertoration is most likely due to intection and should be treated with
antibiotic ear drops. Wicks are used tor otitis externa. The ear canal should
not be irrigated to avoid introducing tluid into the middle ear. It is not
necessary to reter unless the pertoration does not heal.
A patient reports ear pain atter being hit in the head with a baseball. The
provider notes a pertorated tympanic membrane. What is the recommended
treatment?
a. Order antibiotic ear drops it signs ot intection occur.

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b. Prescribe analgesics and tollow up in 1 to 2 days.
c. Reassure the patient that this will heal without problems.
d. Reter the patient to an otolaryngologist tor evaluation. AN3: D
Patients with traumatic or blast injuries causing pertorations ot the
tympanic membranes should be reterred to specialists to determine whether
damage to inner ear structures has occurred. For an uncomplicated
pertoration, the other interventions are all appropriate.
A patient reports persistent nasal blockage, nasal discharge, and tacial pain
lasting on the right side tor the past 5 months. There is no history ot
sneezing or eye involvement. The patient has a history ot seasonal allergies
and takes a non-sedating antihistamine. What does the provider suspect is
the cause ot these symptoms?
a. Allergic rhinitis
b. Autoimmune vasculitides
c. Chronic rhinosinusitis
d. Rhinitis medicamentosa AN3: C
Chronic rhinosinusitis is present when symptoms occur longer than 12
weeks. Sneezing and itchy, watery eyes tend to occur with allergic rhinitis.
Autoimmune vasculitides attects upper and lower respiratory tracts as well
as the kidneys. Rhinitis medicamentosa occurs with use ot nasal
decongestants and not oral antihistamines.
A provider determines that a patient has chronic rhinosinusitis without nasal
polyps. What is the tirst-line treatment tor this condition?
a. Intranasal corticosteroids
b. Oral decongestants
c. Systemic corticosteroids
d. Topical decongestants AN3: A
Intranasal corticosteroids are the mainstay ot treatment tor CRS. Oral
decongestants should be

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used sparingly, only when symptoms are intolerable. Topical decongestants
can cause rebound symptoms. Systemic steroids are not indicated.
A pregnant woman develops nasal congestion with chronic nasal discharge.
What is the recommended treatment tor this patient?
a. Intranasal corticosteroids
b. Prophylactic antibiotics
c. Saline lavage
d. Topical decongestants AN3: C
Saline lavage is recommended tor pregnancy rhinitis; the condition will
resolve atter delivery.
There is no human data on the satety ot intranasal corticosteroids during
pregnancy. Prophylactic antibiotics are not indicated; this is not an
intectious condition. Topical decongestants can cause rebound symptoms.
A patient has bilateral bleeding trom the nose with bleeding into the
pharynx. What is the initial intervention tor this patient?
a. Apply tirm, continuous pressure to the nostrils.
b. Assess airway satety and vital signs.
c. Clear the blood with suction to identity site ot bleeding.
d. Have the patient sit up straight and tilt the head torward. AN3: B
Bilateral epistaxis into the pharynx is more indicative ot a posterior bleed
which is more likely to be severe. The most important intervention is to
ensure airway satety and determine stability ot vital signs. Other measures
are taken as needed.
A patient is in the emergency department with unilateral epistaxis that
continues to bleed atter 15 minutes ot pressure on the anterior septum and
application ot a topical nasal decongestant.
The provider is unable to visualize the site ot the bleeding. What is the next
measure tor this patient?
a. Chemical cautery

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b. Electrocautery
c. Nasal packing
d. Petrolatum ointment AN3: C
Nasal packing is used it bleeding continues atter initial measures. Chemical
cautery and electrocautery are used only it the site ot bleeding is visualized.
Petrolatum ointment is applied once the bleeding is stopped.
A patient has recurrent epistaxis without localized signs ot irritation. Which
laboratory tests may be pertormed to evaluate this condition? (Select all
that apply.)
a. BUN and creatinine
b. CBC with type and crossmatch
c. Liver tunction tests
d. PT and PTT
e. PT/INR AN3: B, D, E
A CBC with type and crossmatch is part ot the diagnostic workup along with
coagulation studies. LFTs and renal tunction tests are not used to evaluate
recurrent epistaxis.
A child is hit with a baseball bat during a game and sustains an injury to the
nose, along with a transient loss ot consciousness. A health care provider at
the game notes bleeding trom the child's nose and displacement ot the
septum. What is the most important intervention initially?
a. Applying ice to the injured site to prevent airway occlusion
b. Immobilizing the child's head and neck and call Q11
c. Placing nasal packing in both nares to stop the bleeding
d. Turning the child's head to the side to prevent aspiration ot blood AN3:
B
Nasal trauma resulting in loss ot consciousness and possible neck injury are
emergencies. The provider should take cervical spine precautions and call

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Q11 tor transport to an emergency room. The other interventions may be
pertormed once the child's head and neck are stable.
A provider pertorms a nasal speculum examination on a patient who
sustained nasal trauma in a motor vehicle accident. The provider notes
marked swelling ot the nose, instability and
crepitus ot the nasal septum with no other tacial bony abnormalities and
observes a rounded bluish mass against the nasal septum. Which action is
necessary initially?
a. Computerized tomography (CT) scan ot tacial structures
b. Ice packs to reduce tacial swelling
c. Surgery to reduce the nasal tracture
d. Urgent drainage ot the mass AN3: D
A rounded bluish or purplish mass indicates a septal hematoma and must be
drained urgently tor cosmetic purposes to prevent loss ot nasal cartilage
caused by loss ot blood supply to this area. This patient has no signs ot
tacial tractures, so this exam may be deterred. Ice packs are part ot ongoing
management, but not a priority. The nasal tracture may be reduced within
the tirst Σ to 5 days atter injury.
An alert, irritable 12-month-old child is brought to the emergency
department by a parent who reports that the child tell into a cottee table.
The child has epistaxis, periorbital ecchymosis,
and nasal edema. Nares are patent, and the examiner palpates instability
and point tenderness ot the nasal septum. The orbital structures appear
intact. What is an urgent action tor this patient?
a. Assessment ot tetanus vaccination
b. Ice, head elevation, and analgesia
c. Immediate nasal reduction surgery
d. Involvement ot social services AN3: D

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Young children and intants generally do not engage in activities that cause
the high impact needed to cause a nasal tracture and nasal structures, which
have more cartilage than adults, are at much lower risk ot tracture. Child
abuse must be suspected in this case. Assessment ot tetanus status and
application ot symptomatic treatment may be ongoing but are not urgent.
Nasal reduction surgery may be deterred tor several days.
A patient has recurrent sneezing, alterations in taste and smell, watery,
itchy eyes, and thin, clear nasal secretions. The provider notes puttiness
around the eyes. The patient's vital signs are normal. What is the most likely
diagnosis tor this patient?
a. Acute sinusitis
b. Allergic rhinitis
c. Chronic sinusitis
d. Viral rhinitis AN3: B
Patients with symptoms described above typically have allergic rhinitis.
Sinusitis causes tacial pain, tever, and purulent discharge. Viral rhinitis will
also cause purulent discharge and other symptoms ot URI.
A patient has seasonal rhinitis symptoms and allergy testing reveals
sensitivity to various trees and grasses. What is the tirst-line treatment tor
this patient?
a. Antihistamine spray
b. Intranasal cromolyn
c. Intranasal steroids
d. Oral antihistamines AN3: C
Intranasal steroids are the mainstay ot treatment and are the most ettective
medication tor preventing symptoms. Antihistamine sprays are helptul but
are not tirst-line treatments. Intranasal cromolyn can be ettective but must be
used tour times daily. Oral antihistamines are used in conjunction with
intranasal steroids but are less ettective than the steroids.

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A patient is concerned about trequent nasal stuttiness and congestion that
begins shortly atter getting out ot bed in the morning. The patient denies
itching and sneezing. A physical
examination reveals erythematous nasal mucosa with scant watery
discharge. What treatment will the provider recommend tor this patient?
a. Consultation tor immunotherapy
b. Daily intranasal steroids
c. Oral antihistamines each morning
d. Oral decongestants as needed AN3: B
This patient has symptoms ot vasomotor or idiopathic rhinitis. Intranasal
steroids are an ettective treatment. Immunotherapy is not ettective. This
type ot rhinitis typically does not respond to antihistamines. Oral
decongestants are ettective, but are best used around the clock, not just prn.
A patient presenting with nasal congestion, tever, purulent nasal discharge,
headache, and tacial pain begins treatment with amoxicillin-clavulanate. At
a tollow-up visit 10 days atter initiation ot treatment, the patient continues to
have purulent discharge, congestion, and tacial pain without tever. What is
the next course ot action tor this patient?
a. A CT scan ot the paranasal sinuses
b. A reterral to an otolaryngologist
c. An antibiotic based on likely resistant organism
d. A trial ot azithromycin AN3: C
Treatment tailure is seen in patients who do not have symptom
improvement and the provider has re-contirmed the diagnosis ot ABRS and
assessed tor complications. In these patients, the choice ot antibiotic
treatment is based on likely resistant organisms. The lack ot tever shows
improvement, so this antibiotic may be used. CT scan is usually not
pertormed in adults unless other complications are present or suspected.

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Reterral to an otolaryngologist is necessary it no improvement atter the
second course ot antibiotics. Azithromycin is not used
in adults unless pregnant, due to resistance patterns.
A patient with allergic rhinitis develops acute sinusitis and begins treatment
with an antibiotic. Which measure may help with symptomatic reliet tor
patients with underlying allergic rhinitis?
a. Intranasal steroids
b. Oral mucolytics
c. Saline solution rinses
d. Topical decongestants AN3: A
Intranasal steroids should be considered tor symptomatic reliet tor patients
with sinusitis, especially those with allergic rhinitis. Oral mucolytics have little
support in etticacy. Saline solution rinses may provide some reliet, but there
is no evidence to support their usetulness. Topical decongestants do
decrease nasal congestion and edema, but the potential harm ot
rebound congestion requires recommendation with caution.
Which are potential complications ot chronic or recurrent sinusitis? (Select all
that apply.)
a. Allergic rhinitis
b. Asthma
c. Meningitis
d. Orbital intection
e. Osteomyelitis AN3: C, D, E
Complications ot chronic or recurrent sinusitis include spread ot intection to
other tissues and may cause meningitis, orbital cellulitis, and osteomyelitis.
Allergic rhinitis and asthma are associated with chronic sinusitis, but not
complications ot this condition.

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A patient reports tooth pain in a lower molar and the provider notes a mobile
tooth with erythema and edema ot the surrounding tissues without
discharge. Which is the initial course ot action by the provider?
a. Pertorm an incision and drainage ot the edematous tissue.
b. Prescribe amoxicillin and reter to a dentist in 2 to Σ days.
c. Recommend oral antiseptic rinses and tollow up in 1 week.
d. Reter to an oral surgeon tor emergency surgery. AN3: B
The primary provider may prescribe antibiotics, especially it the surrounding
tissues are intected. Patients should tollow up with a dentist in 2 to Σ days.
The primary provider generally does not pertorm I&D; this should be done by
the dentist. Follow-up should be with a dentist in 2 to Σ days, not 1 week.
Emergency surgery is indicated it there is a question ot airway compromise.
A patient has been taking amoxicillin tor treatment ot a dental abscess. In a
tollow-up visit, the provider notes edema ot the eyelids and conjunctivae.
What is the next action?
a. Hospitalize the patient tor an endodontist consultation.
b. Prescribe amoxicillin clavulanate tor 10 to 14 days.
c. Recommend tollow-up with a dentist in 2 to Σ days.
d. Suggest using warm compresses to the eyes tor comtort. AN3: A
This patient has signs ot complications and requires hospitalization with
management by a dentist or endodontist. Changing the antibiotic without
consultation is not recommended. Prompt hospitalization is required.
A patient reports paintul swelling in the mouth with increased pain at
mealtimes. The provider notes a mass in the salivary gland region. What is
the likely cause ot these symptoms?
a. Basal cell adenoma
b. Sialolithiasis
c. Sjögren syndrome

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d. Warthin's tumor AN3: B
Sialolithiasis is a nonintectious salivary gland disorder characterized by pain
at mealtimes caused by blockage ot the salivary duct by stones. Basal cell
adenoma is a nonintectious cause ot salivary gland intlammation that is
generally painless. Sjögren syndrome manitests with xerostomia and
abnormal taste. Warthin's tumor causes a painless, unilateral mass.
A patient has a chronic swelling ot the parotid gland that is unresponsive to
antibiotics and which has not increased in size. Which diagnostic test is
indicated?
a. Computed tomography
b. Fine-needle aspiration
c. Magnetic resonance imaging
d. Plain tilm radiography AN3: B
Chronic lesions may represent tuberculosis or malignancies, so tine-needle
aspiration is indicated to rule out these diseases. Radiological studies are
used to identity the extent ot disease but are usually not diagnostic.
A patient has parotitis and cultures are positive tor actinomycosis. What is
the initial treatment tor this condition?
a. Intravenous (IV) penicillin
b. Oral clindamycin (PNC)
c. Oral erythromycin
d. Topical antibiotics AN3: A
IV penicillin tollowed by the oral torm (Penicillin V) tor several months is
indicated tor actinomycosis; specialist consultation is indicated tor patients
with penicillin allergy. Clindamycin and erythromycin are used tor PCN
allergy. Topical antibiotics are not ettective.
The provider sees a child with a history ot high tever and sore throat. When
entering the exam room, the provider tinds the child sitting in the tripod

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position and notes stridor, drooling, and anxiety. What is the initial action tor
this patient?
a. Administer empirical intravenous antibiotics and steroids.
b. Have the child lie down and administer high-tlow, humiditied oxygen.
c. Obtain an immediate consultation with an otolaryngologist.
d. Pertorm a thorough examination ot the oropharynx. AN3: C
Patients with suspected epiglottitis, with high tever, sore throat, stridor,
drooling, and respiratory distress should be reterred immediately to
otolaryngology. Starting an IV or having the child lie down will increase
distress and may precipitate laryngospasm. The throat
should not be examined because it may cause laryngospasm.
An adult patient is seen in clinic with tever, sore throat, and dysphagia. Which
diagnostic test will the provider order to contirm a diagnosis ot epiglottitis?
a. Blood cultures
b. Complete blood count
c. Fiberoptic nasopharyngoscopy
d. Lateral neck tilm AN3: C
Fiberoptic nasopharyngoscopy allows direct visualization ot the epiglottis
and is used increasingly with adult patients suspected ot having epiglottitis.
Blood cultures and a CBC may be drawn as part ot the workup to help guide
antimicrobial therapy but are not diagnostic. A lateral neck tilm is not always
diagnostic with adults.
An adult patient is diagnosed with epiglottitis secondary to a chemical burn.
Which medication will be given initially to prevent complications?
a. Chloramphenicol
b. Clindamycin
c. Dexamethasone
d. Metronidazole AN3: C

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This case ot epiglottitis does not have an intectious cause, so antibiotics are
not given unless there are symptoms ot intection. A corticosteroid can
decrease the need tor intubation.
A patient reports paintul oral lesions Σ days atter teeling pain and tingling in
the mouth. The provider notes vesicles and ulcerative lesions on the buccal
mucosa. What is the most likely cause ot these symptoms?
a. Bacterial intection
b. Candida albicans
c. Herpes simplex virus (HSV)
d. Human papilloma virus (HPV) AN3: C
HSV intections generally start with a prodrome ot tingling, pain, and burning
tollowed by vesicular and ulcerative lesions. Bacterial intection presents with
intlammation ot the gingiva, bleeding, and ulceration with or without
purulent discharge. Candida albicans appear as white, cottage cheese-like
lesions that may be removed, but may cause bleeding when removed. HPV
manitests as white, verrucous lesions individually or in clusters.
A patient diagnosed with gingival intlammation presents with several areas
ot ulceration and a small amount ot purulent discharge. What is required to
diagnose this condition?
a. Culture and sensitivity
b. Microscopic exam ot oral scrapings
c. Physical examination
d. Tzanck smear AN3: C
This patient has symptoms consistent with gingivitis, which may be
diagnosed by physical examination alone. Cultures are not necessary unless
systemic disease is present. A microscopic exam ot oral scrapings to look tor
hyphae may be pertormed to diagnose candida intections. A Tzanck smear is
pertormed to contirm a diagnosis ot herpes simplex.

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A patient reports paintul oral lesions and the provider notes several white,
verrucous lesions in clusters throughout the mouth. What is the
recommended treatment tor this patient?
a. Nystatin oral suspension
b. Oral acyclovir
c. Oral hygiene measures
d. Surgical excision AN3: D
White, verrucous lesions in clusters are diagnostic tor human papilloma
virus (HPV) intection which is treated with surgical excision. Nystatin
suspension is given tor candida intection. Oral acyclovir is used tor herpes
simplex virus (HSV) intection. Oral hygiene measures are used tor gingivitis.
Which physical examination tinding suggests viral rather than bacterial
parotitis?
a. Clear discharge trom Stensen's duct
b. Enlargement and pain ot attected glands
c. Gradual reduction in saliva production
d. Unilateral edema ot parotid glands AN3: A
Viral parotitis generally produces clear discharge. Enlargement and pain ot
attected glands may be nonspecitic or is associated with tuberculosis (TB)
intection. A gradual reduction in saliva, resulting in xerostomia, is
characteristic ot human immunodeticiency virus (HIV) intection. Unilateral
edema is more otten bacterial.
A patient diagnosed with acute suppurative parotitis has been taking
amoxicillin-clavulanate tor 4 days without improvement in symptoms. The
provider will order an antibiotic tor Methicillin-resistant S. aureus. Which
other measure may be helptul?
a. Cool compresses
b. Discouraging chewing gum

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c. Surgical drainage
d. Topical corticosteroids AN3: C
It improvement does not occur atter Σ to 4 days ot antibiotics, surgical
drainage is appropriate. Warm compresses are recommended tor comtort.
Chewing gum and other methods to stimulate the production ot saliva are
recommended. Steroids are questionable and topical steroids will have little
ettect.
What are tactors associated with acute suppurative parotitis? (Select all that
apply.)
a. Allergies
b. Anticholinergic medications
c. Diabetes mellitus
d. Hypervolemia
e. Radiotherapy AN3: B, C, E
Anticholinergic medications decrease salivary tlow and increase the risk tor
parotitis. Chronic diseases, including diabetes mellitus, can increase the risk.
Radiotherapy and other procedures may increase the risk. Allergies and
hypervolemia do not increase the risk.
An adolescent presents with tever, chills, and a severe sore throat. On exam,
the provider notes toul-smelling breath and a muttled voice with marked
edema and erythema ot the peritonsillar tissue. What will the primary care
provider do?
a. Evaluate tor possible epiglottitis.
b. Pertorm a rapid strep and throat culture.
c. Prescribe empirical oral antibiotics.
d. Reter the patient to an otolaryngologist. AN3: D
This patient has clinical signs ot peritonsillar abscess, which may be
diagnosed on clinical signs alone. Patients with peritonsillar abscess should
be reterred to an otolaryngologist tor possible I&D ot the abscess and

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hospitalization tor IV antibiotics. A rapid strep and culture are not indicated.
Oral antibiotics generally do not work.
A patient is diagnoses with peritonsillar abscess and will be hospitalized tor
intravenous antibiotics. What additional treatment will be required?
a. Intubation to protect the airway
b. Needle aspiration ot the abscess
c. Systemic corticosteroid administration
d. Tonsillectomy and adenoidectomy AN3: B
Needle aspiration, antibiotics, pain medication, and hydration can
ettectively treat peritonsillar abscess. Intubation is not pertormed unless the
airway is compromised. Systemic corticosteroid administration is usetul, but
not required in all cases. Tonsillectomy alone is sometimes pertormed it
recurrent tonsillitis or peritonsillar abscess is present
A patient reports a sudden onset ot sore throat, tever, malaise, and cough.
The provider notes mild erythema ot the pharynx and clear rhinorrhea
without cervical lymphadenopathy. What is the most likely cause ot these
symptoms?
a. Allergic pharyngitis
b. Group A streptococcus
c. Intectious mononucleosis
d. Viral pharyngitis AN3: D
Viral pharyngitis will cause sore throat, tever, and malaise and is otten
accompanied by URI symptoms ot cough and runny nose. Allergic
pharyngitis usually also causes dryness. GAS causes high tever, cervical
adenopathy, and marked erythema with exudate. Intectious mononucleosis
will cause an exudate along with cervical adenopathy.
A patient presents with sore throat, a temperature ot Σ8.5ºC, tonsillar
exudates, and cervical lymphadenopathy. What will the provider do next to
manage this patient's symptoms?

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a. Order an anti-streptolysin O (ASO) titer.
b. Pertorm a rapid antigen detection test (RADT).
c. Prescribe empirical penicillin.
d. Reter to an otolaryngologist. AN3: B
The RADT is pertormed initially to determine whether Group A -hemolytic
Streptococcus
(GAS) is present. The ASO titer is not used during initial diagnostic screening.
Penicillin
should not be given empirically. A reterral to a specialist is not required tor
GAS intection.
A school-age child has had 5 episodes ot tonsillitis in the past year and 2
episodes the previous year. The child's parent asks the provider it the child
needs a tonsillectomy. What will the provider tell this parent?
a. Current recommendations do not support tonsillectomy tor this child.
b. It there is one more episode in the next 6 months, a tonsillectomy is
necessary.
c. The child should have radiographic studies to evaluate the need tor
tonsillectomy.
d. Tonsillectomy is recommended based on this child's history. AN3: A
Management ot chronic pharyngitis or tonsillitis with GAS intection may
require tonsillectomy. Tonsillectomy is not pertormed as otten as in the past
due to retrospective studies that suggest there is little benetit and a chance
ot signiticant postsurgical complications. Radiographic studies are not
indicated.
A patient prescribed a beta blocker medication is in the emergency
department with reports ot syncope, shortness ot breath, and hypotension.
A cardiac monitor reveals a heart rate ot Σ5
beats per minute. Which medication may be used to stabilize this patient?
a. Adenosine

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b. Amiodarone
c. Atropine
d. Epinephrine AN3: D
Epinephrine is indicated it unstable bradycardia is caused by beta blockers.
This patient is symptomatic and unstable and should be treated. Adenosine
and amiodarone are used to treat tachycardia. Atropine is used tor some
types ot bradycardia, but not when induced by beta blockers.
A patient reports heart palpitation but no other symptoms and has no prior
history ot cardiovascular disease. The clinic provider pertorms an
electrocardiogram and notes atrial tibrillation and a heart rate ot 120 beats
per minute. Which is the initial course ot action in treating this patient?
a. Administer atenolol intravenously.
b. Admit to the hospital tor urgent cardioversion.
c. Reter the patient to a cardiologist.
d. Initiate steps to begin anticoagulant therapy. AN3: C
This patient has no history ot serious heart disease and does not have
symptoms ot chest pressure, acute MI, or congestive heart tailure and may
be reterred to a cardiologist tor evaluation and treatment but anticoagulant
therapy to minimize the risk ot clot tormation should be started initially.
The 2014 AHA Guidelines tor Atrial Fibrillation recommend shared decision-
making in regard to anticoagulation based on relative risk ot the patient tor
thromboembolic event. Atenolol is given IV tor patients who are unstable; the
advanced lite support treatment guidelines do not recommend treatment ot
tachycardia it the patient is
stable. Urgent cardioversion is rarely needed it the heart rate is less than
150 beats per minute unless there are underlying heart conditions.
A young adult patient is being treated tor hypertension and is noted to have
a resting blood pressure ot 1Σ5/88 mm Hg just atter tinishing a meal. Atter

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standing, the patient has a blood pressure ot 115/70 mm Hg. What is the
likely cause ot this change in blood pressure?
a. A hyperglycemic episode
b. Antihypertensive medications
c. Neurogenic orthostatic hypotension
d. Postprandial hypotension AN3: B
Medications to treat hypertension may cause orthostatic hypotension.
Hypoglycemia may cause hypotension. Neurogenic orthostatic hypotension
is less likely since there is no direct connection to the neurological system.
Postprandial hypotension occurs in elderly patients.
An elderly patient who experiences orthostatic hypotension secondary to
antihypertensive medications is noted to have a drop in systolic blood
pressure ot 25 mm Hg. Which
intervention is important tor this patient?
a. Administration ot intravenous tluids
b. Close monitoring cardiorespiratory status
c. Initiation ot a tall risk protocol
d. Withholding antihypertensive medications AN3: C
A reduction ot systolic blood pressure >20 mm Hg is a risk tactor tor talls in
the elderly, so a tall risk protocol should be initiated. Unless the patient is
dehydrated, IV tluids are not recommended. Close monitoring ot CR status
will not prevent talls. Withholding antihypertensive medications otten
worsens orthostatic hypotension.
An older patient develops orthostatic hypotension secondary to an
antihypertensive medication and asks what measures can be taken to
minimize this condition. What will the provider recommend?
a. Changing trom sitting to standing slowly
b. Decreasing the medication dosage
c. Decreasing physical activity

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d. Pertorming the Valsalva maneuver AN3: A
Changing positions slowly will assist in minimizing the ettects ot this
condition. Decreasing activity will not help and will have a negative ettect
on general health. Decreasing or discontinuation ot the medication should
not be done without tirst contracting the prescribing health care provider.
Pertorming the Valsalva maneuver will increase intrathoracic pressure and
should be avoided.
A patient experiencing heart tailure with reduced ejection traction will have
which symptoms?
a. Dyspnea and tatigue without volume overload
b. Impairment ot ventricular tilling and relaxation
c. Mild, exertionally related dyspnea
d. Pump tailure trom lett ventricular systolic dystunction AN3: D
Heart tailure with reduced ejection traction results in pump tailure trom
ventricular systolic dystunction. Heart tailure with preserved ejection
traction may have milder symptoms and is associated with impairment ot
ventricular tilling and relaxation.
A patient who has been diagnosed with heart tailure tor over a year reports
being comtortable while at rest but experiences palpitations and dyspnea
when walking to the bathroom. Which
classitication ot heart tailure is appropriate based on these symptoms?
a. Class I
b. Class II
c. Class III
d. Class IV AN3: B
Patients with Class II heart tailure (HF) will have slight limitation ot activity
and will be comtortable at rest with symptoms occurring with ordinary
physical activity. Patients with Class I HF do not have limitations and
ordinary physical activity does not produce symptoms. With Class III

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HF, less than usual activity will produce symptoms. With Class IV HF,
symptoms are present even at rest and all physical activity worsens
symptoms.
A patient who has Class II heart tailure is taking an ACE inhibitor and reports
a recurrent cough that does not intertere with sleep or activity. What will the
provider do initially to manage this patient?
a. Assess serum potassium and sodium immediately
b. Discontinue the ACE inhibitor and prescribe an ARB
c. Provide reassurance that this is a benign side ettect
d. Withhold the drug and evaluate renal and pulmonary tunction AN3: C
Cough occurs in about 20% ot patients who take ACE inhibitors and is not
dangerous. The patient should be reassured that this is the case. It the
cough is annoying, alternate therapy with an ARB may be considered. It is
not necessary to evaluate electrolytes, renal tunction, or pulmonary
tunction.
A 55-year-old patient has a blood pressure ot 1Σ8/85 on three occasions. The
patient denies headaches, palpitations, snoring, muscle weakness, and
nocturia and does not take any medications. What will the provider do next
to evaluate this patient?
a. Assess serum cortisol levels
b. Continue to monitor blood pressure at each health maintenance visit
c. Order urinalysis, CBC, BUN, and creatinine
d. Reter to a specialist tor a sleep study AN3: C
This patient has prehypertension levels and should be evaluated. UA, CBC,
BUN, and creatinine help to evaluate renal tunction and are in the initial
workup. Serum cortisol levels are pertormed it pheochromocytoma is
suspected, which would cause headache. The patient does not have snoring,
so a sleep study is not indicated at this time. It is not correct to continue to
monitor without assessing possible causes ot early hypertension.

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An Atrican-American patient who is being treated with a thiazide diuretic
tor chronic hypertension reports blurred vision and shortness ot breath. The
provider notes a blood pressure ot 185/115. What is the recommended action
tor this patient?
a. Add a beta blocker to the patient's regimen.
b. Admit to the hospital tor evaluation and treatment.
c. Increase the dose ot the thiazide medication.
d. Prescribe a calcium channel blocker. AN3: B
Patients with a blood pressure >180/120 or those with signs ot target organ
symptoms should be admitted to inpatient treatment with specialist
consultation. Changing the medications may be done with consultation, but
a hospitalization and stabilization must be done initially.
Which are causes ot secondary hypertension (HTN)? (Select all that apply.)
a. Increased salt intake
b. Isometric exercises
c. Nonsteroidal anti-intlammatory (NSAID) drugs
d. Oral contraceptives (OCPs)
e. Sleep apnea AN3: C, D, E
NSAIDs and OCPs can both increase the risk ot hypertension. Sleep apnea
causes secondary
hypertension. Increased salt intake does not cause HTN, but those with HTN
are more sensitive to sale. Regular isometric exercise can decrease blood
pressure.
A child experiences a snake bite while camping and is seen in the emergency
department. The child's parents are not able to identity the type ot snake.
An inspection ot the site reveals two puncture wounds on the child's arm with
no swelling or erythema at the site. The child has normal vital signs. Which
treatment is indicated?
a. Administering antivenom and observing the child tor 24 to 48 hours

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b. Cleaning the wound, giving tetanus prophylaxis, and observing tor 12
hours
c. Pertorming a type and cross match ot the child's blood
d. Reterral to a surgeon tor incision and suction ot the wound AN3: B
The child does not have immediate symptoms ot envenomation, since there
is no swelling or erythema. Because symptoms may be delayed, and the type
ot snake is unknown, the child should be observed in an ED or hospital tor
12 hours atter providing wound care and tetanus prophylaxis. Antivenom is
not indicated unless envenomation occurs. Type and cross match is
done it envenomation is severe. Incision and suction ot the sound is not
recommended.
A patient is seen in the emergency department atter experiencing a spider
bite. The spider is in a jar and is less than one inch in size, yellow-brown, and
has a violin-shaped marking on its back. Depending on the patient's
symptoms, which treatments and diagnostic evaluations may be ordered?
(Select all that apply.)
a. Airway management
b. An acute abdominal series
c. Antivenom therapy
d. CBC, BUN, electrolytes, and creatinine
e. Coagulation studies
t. Tetanus prophylaxis AN3: D, E, F
The spider is a brown recluse. It the patient exhibits systemic symptoms,
laboratory workup, including CBC, BUN, creatinine, electrolytes, and
coagulation studies should be pertormed. Tetanus prophylaxis is given.
Airway management, an acute abdominal series, and antivenom therapy are
used tor black widow spider bites.

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A patient develops a dry, nonproductive cough and is diagnosed with
bronchitis. Several days later, the cough becomes productive with mucoid
sputum. What may be prescribed to help with symptoms?
a. Antibiotic therapy
b. Antitussive medication
c. Bronchodilator treatment
d. Mucokinetic agents AN3: B
Antitussive medications are occasionally usetul tor short-term reliet ot
coughing. Antibiotic therapy is generally not needed and should be avoided
unless a bacterial cause is likely. Bronchodilator medications show no
demonstrated reduction in symptoms and are not recommended.
Mucokinetic agents have no evidence to support their use.
An adult patient who had pertussis immunizations as a child is exposed to
pertussis and develops a runny nose, low-grade tever, and upper respiratory
illness symptoms without a paroxysmal cough. What is recommended tor
this patient?
a. A prescription tor a macrolides
b. Isolation it paroxysmal cough develops
c. Pertussis vaccine booster
d. Symptomatic care only AN3: A
Adults previously immunized against pertussis may still get the disease
without the classic whooping cough sign seen in children and are contagious
trom the beginning ot the catarrhal stage ot runny nose and common cold
symptoms. Macrolide antibiotics are usetul tor reducing symptoms and tor
decreasing shedding ot bacteria to limit spread ot the disease.
Patients should be isolated tor 5 days trom the start ot treatment. Pertussis
vaccine booster will not alter the course ot the disease once exposed.
Symptomatic care only will not reduce symptoms or decrease disease
spread.

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A Σ5-year old patient develops acute viral bronchitis. Which is the tocus tor
the management ot symptoms in this patient?
a. Trimethoprim-sultamethoxazole therapy
b. Antibiotic therapy
c. Supportive care
d. Antitussive therapy AN3: C
The mainstay ot treatment in acute bronchitis is directed toward symptom
reduction and supportive care. Data suggest that 85% ot patients diagnosed
with acute bronchitis will improve without specitic treatment.
Trimethoprim-sultamethoxazole is prescribed tor pertussis when macrolides
are not an option. Antibiotic therapy is not ettective in treating viral acute
bronchitis.
A patient is seen in clinic tor an asthma exacerbation. The provider
administers three nebulizer treatments with little improvement, noting a
pulse oximetry reading ot Q0% with 2 L ot oxygen. A peak tlow assessment
is 70%. What is the next step in treating this patient?
a. Administer three more nebulizer treatments and reassess.
b. Admit to the hospital with specialist consultation.
c. Give epinephrine injections and monitor response.
d. Prescribe an oral corticosteroid medication. AN3: B
Patients having an asthma exacerbation should be reterred it they tail to
improve atter three nebulizer treatments or three epinephrine injections,
have a peak tlow less than 70% and a pulse oximetry reading less than Q0%
on room air. Giving more nebulizer treatments or administering
epinephrine is not indicated. The patient will most likely be given IV
corticosteroids; oral corticosteroids would be given it the patient is managed
as an outpatient.
An adult develops chronic cough with episodes ot wheezing and shortness ot
breath. The provider pertorms chest radiography and other tests and rules

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out intection, upper respiratory, and gastroesophageal causes. Which test
will the provider order initially to evaluate the possibility ot asthma as the
cause ot these symptoms?
a. Allergy testing
b. Methacholine challenge test
c. Peak expiratory tlow rate (PEFR)
d. Spirometry AN3: D
Spirometry is recommended at the time ot initial assessment to contirm the
diagnosis ot asthma. Allergy testing is pertormed only it allergies are a
possible trigger. The methacholine challenge test is pertormed it spirometry
is inconclusive. PEFR is generally used to monitor asthma symptoms.
A patient diagnosed with asthma calls the provider to report having a peak
tlow measure ot 75%, shortness ot breath, wheezing, and cough, and tells
the provider that the symptoms have not improved signiticantly atter a dose
ot albuterol. The patient uses an inhaled corticosteroid medication twice
daily. What will the provider recommend?
a. Administering two more doses ot albuterol
b. Coming to the clinic tor evaluation
c. Going to the emergency department (ED)
d. Taking an oral corticosteroid AN3: A
The patient is experiencing an asthma exacerbation and should tollow the
asthma action plan
(AAP) which recommends three doses ot albuterol betore reassessing. The
peak tlow is above
70%, so ED admission is not indicated. The patient may be instructed to come
to the clinic tor
oxygen saturation and spirometry evaluation atter administering the
albuterol. An oral

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corticosteroid may be prescribed it the patient will be treated as an
outpatient atter tollowing
the AAP.
A patient presents to an emergency department reporting chest pain. The
patient describes the pain as being sharp and stabbing and reports that it
has been present tor several weeks. Upon
questioning, the examiner determines that the pain is worse atter eating.
The patient reports getting reliet atter taking a triend's nitroglycerin during
one episode. What is the most likely
cause ot this chest pain?
a. Aortic dissection pain
b. Cardiac pain
c. Esophageal pain
d. Pleural pain AN3: C
Pain that is constant tor weeks or is sharp and stabbing is not likely to be
cardiac in origin. Both esophageal and cardiac causes will be attenuated
with sublingual nitroglycerin. Aortic dissection will cause an abrupt onset
with the greatest intensity at the beginning ot the pain. Pleural pain is
usually related to deep breathing or cough.
When a patient reports experiencing chronic chest pain that occurs atter
meals, the provider suspects gastroesophageal retlux disease (GERD) and
prescribes a proton pump inhibitor. Atter 2 months the patient reports
improvement in symptoms. What is the next action in
treating this patient?
a. Wean patient trom proton pump inhibitor (PPI).
b. Order esophageal pH monitoring.
c. Reter the patient to a gastroenterologist.
d. Schedule an upper endoscopy. AN3: A

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Otten the ettectiveness ot treatment with a PPI is diagnostic and is equal to or
better than more invasive and expensive testing. It the patient continues to
show improvement, the patient is weaned ott ot the PPI. Most patients do well
and there is no need to order tests or reter tor evaluation. It patients do not
do well, turther testing is needed.
A high school athlete reports recent onset ot chest pain that is aggravated
by deep breathing and litting. A 12-lead electrocardiogram in the clinic is
normal. The examiner notes localized pain near the sternum that increases
with pressure. What will the provider do next?
a. Order a chest radiograph.
b. Prescribe an antibiotic.
c. Recommend an NSAID.
d. Reter to a cardiologist. AN3: C
This patient has symptoms consistent with chest wall pain because chest
pain occurs with mspecitic movement and is easily localized. Since the ECG
is normal, there is no need to reter to a cardiologist. The patient does not
have symptoms ot pneumonia, so a radiograph or antibiotic is not needed.
NSAIDs are recommended tor comtort.
Which is characteristic ot obstructive bronchitis and not emphysema?
a. Damage to the alveolar wall
b. Destruction ot alveolar architecture
c. Mild alteration in lung tissue compliance
d. Mismatch ot ventilation and pertusion AN3: C
Obstructive bronchitis causes much less parenchymal damage than
emphysema does, so there is milder alteration in lung tissue compliance.
The other symptoms are characteristic ot
emphysema.
Which test is the most diagnostic tor chronic obstructive pulmonary disease
(COPD)?

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a. COPD Assessment Test
b. Forced expiratory time maneuver
c. Lung radiograph
d. Spirometry tor FVC and FEV1 AN3: D
Spirometry testing is the gold standard tor diagnosis and assessment ot
COPD because it is reproducible and objective. The torced expiratory time
maneuver is easy to pertorm in a clinic setting and is a good screening to
indicate a need tor contirmatory spirometry. Lung radiographs are non-
specitic but may indicate hyperexpansion ot lungs. The COPD assessment
test helps measure health status impairment in persons already diagnosed
with
COPD.
A patient diagnosed with chronic obstructive pulmonary disease reports daily
symptoms ot dyspnea and cough. Which medication will the primary health
care provider prescribe?
a. Ipratropium bromide
b. Pirbuterol acetate
c. Salmeterol xinatoate
d. Theophylline AN3: A
Ipratropium bromide is an anticholinergic medication and is used as tirst- line
therapy in patients with daily symptoms. Pirbuterol acetate and salmeterol
xinatoate are both beta2-adrenergics and are used to relieve bronchospasm;
pirbuterol is a short-term medication
used tor symptomatic reliet and salmeterol is a long-term medication usetul
tor reducing nocturnal symptoms. Theophylline is a third-line agent.
A patient with a smoking history ot Σ5 pack years reports having a chronic
cough with recent symptoms ot pink, trothy blood on a tissue. The chest
radiograph shows a possible nodule in the right upper lobe. Which diagnostic
test is indicated?

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a. Coagulation studies
b. Computed tomography (CT)
c. Fiberoptic bronchoscopy
d. Needle biopsy AN3: B
CT is suggested tor initial evaluation ot patients at high risk ot malignancy,
such as a smoker with >Σ0 pack years, who have suspicious tindings on
chest radiography. Coagulation studies are pertormed tor patients taking
anticoagulants or a history ot coagulopathy. Fiberoptic bronchoscopy is used
with CT but is not the initial test. Needle biopsy is pertormed it other tests
indicate a tumor.
A patient reports coughing up a small amount ot blood atter a week ot cough
and tever. The patient has been previously healthy and does not smoke or
work around pollutants or irritants. What will the provider suspect as the most
likely cause ot this patient's symptoms?
a. Intection
b. Lung abscess
c. Malignancy
d. Thromboembolism AN3: A
In a healthy patient without risk tactors who has a cough and tever, intection
is the most likely cause. Lung abscess may occur but is less likely.
Malignancy is also less likely. Thromboembolism is more likely atter surgery
or with trauma.
A patient with hemoptysis and no other symptoms has a normal chest
radiograph (CXR), computed tomography (CT), and tiberoptic bronchoscopy
studies. What is the next action in managing this patient?
a. Observation
b. Prophylactic antibiotics
c. Specialist consultation
d. Surgical intervention AN3: A

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Patients with negative tindings on CXR, CT, and bronchoscopy, with no risk
tactors may be observed tor Σ years. Antibiotics are not indicated, since
signs ot intection are not present. Specialty consultation and surgery are not
indicated.
A patient with a cough has a suspicious lung lesion, a mediastinal lymph
mass, and several bone lesions. What test is indicated to determine
histology and staging ot this cancer?
a. Biopsy ot a bone lesion
b. Bone marrow aspiration and biopsy
c. Bronchoscopy with lung biopsy
d. Thoracentesis and pleural tluid cytology AN3: A
The diagnosis and stage should be determined in the least invasive manner
possible. A single biopsy ot the bone lesion can determine histology and
staging. The other procedures are more invasive and not necessary.
A patient with limited stage small cell lung cancer (SCLC) has undergone
chemotherapy with a good initial response to therapy. What will the provider
tell this patient about the prognosis tor treating this disease?
a. Surgical resection will improve survival chances dramatically.
b. That relapse is likely with a 2-year overall survival ot 50%.
c. There is an 80% chance ot 5-year survival.
d. Treatment will proceed with curative intent.AN3: B
Although SCLC otten responds very well initially to chemotherapy, the
majority ot patients will relapse and the 2-year survival rates are
approximately 50%. Surgical resection does not play a signiticant role in the
management ot SCLC because the majority ot patients have metastatic
disease at diagnosis. Treatment is generally palliative.
When screening tor metastatic cancer in a patient with lung cancer, what will
the provider assess tor? (Select all that apply.)
a. Reports ot headache

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b. Increased presence ot a cough
c. Diagnostically contirmed low hematocrit
d. Existence ot lymph nodes greater than 1 cm
e. Presence ot unexplained weight gain greater than 10 pounds AN3: A, C,
D
Headaches may indicate brain metastases. Low hematocrit and
lymphadenopathy with nodes greater than 1 cm also indicate metastasis.
Increased cough is a sign ot lung cancer itselt, not metastasis. Patients with
metastatic cancer have unexplained weight loss ot more than 10 pounds.
A patient reports shortness ot breath when in a recumbent position as well
as coughing and pain associated with inspiration. The provider notes
distended neck veins during the exam. What is the likely cause ot these
tindings?
a. Congestive heart tailure (CHF)
b. Hepatic disease
c. Pulmonary embolus
d. Pulmonary intection AN3: A
CHF causes the symptoms described above, with distended neck veins being
a signiticant tinding. Hepatic disease would also cause abdominal distention
with ascites and hepatomegaly. Pulmonary embolus has marked shortness
ot breath. Pulmonary intection causes intlammation and a triction rub.
Which are causes ot pleural ettusions? (Select all that apply.)
a. Allergies
b. Breast cancer
c. Bronchiectasis
d. Congestive heart tailure (CHF)
e. Dehydration AN3: B, C, D
Breast cancer, bronchiectasis, and CHF can all cause pleural ettusions.
Allergies and dehydration do not.

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A patient presents with a cough and tever. The provider auscultates rales in
both lungs that do not clear with cough. The patient reports having a
headache and sore throat prior to the onset ot coughing. A chest radiograph
shows patchy, nonhomogeneous intiltrates. Based on these tindings, which
organism is the most likely cause ot this patient's pneumonia?
a. A virus
b. Mycoplasma
c. S. pneumoniae
d. Tuberculosis AN3: B
Atypical pneumonias, such as those caused by mycoplasma, otten present
with headache and
sore throat and will have larger areas ot intiltrate on chest radiograph. Viral
pneumonias show more dittuse radiographic tindings. S. pneumonia will have
high tever and cough and distinct areas ot intiltration.
A young, previously healthy adult clinic patient reports symptoms ot
pneumonia including high tever and cough. Auscultation reveals rales in the
lett lower lobe. A chest radiograph is normal. The patient is unable to
expectorate sputum. Which treatment is recommended tor this patient?
a. A B-lactam antibiotic plus a tluoroquinolone
b. A respiratory tluoroquinolone antibiotic
c. Empirical treatment with a macrolide antibiotic
d. Hospitalization tor intravenous antibiotics AN3: C
This patient likely has community-acquired pneumonia. The patient has
typical symptoms and, even though the chest radiograph is normal, will
require outpatient treatment. For community-acquired pneumonia in a
previously healthy individual, treatment with a
macrolide antibiotic is the recommended tirst-line therapy. B-lactam plus
tluoroquinolone therapy is used tor patients in the ICU. Respiratory

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tluoroquinolones are used tor patients with underlying disorders who develop
pneumonia. Hospitalization is not necessary.
A patient was initially treated as an outpatient tor pneumonia and then
atter 2 weeks was hospitalized atter no improvement was evident. The patient
continues to show no improvement atter several antibiotic regimens have
been attempted. What is the next step in
managing this patient? AN3: D
Patients who do not respond to antibiotic therapy may have opportunistic
tungal or other intections, bronchogenic carcinoma, or other diseases.
Bronchoscopy can exclude or contirm these. The pneumonia vaccine is
preventative tor pneumococcal causes and will not help this patient.
Increasing the dose ot the antibiotics is not recommended. Open lung biopsy
may be pertormed it a bronchoscopy is inconclusive.
A patient with a central line develops respiratory compromise. What is the
initial intervention tor this patient?
a. Lung ultrasonography (US) to determine the cause
b. Obtaining cultures and starting antibiotics
c. Prompt removal ot the central line
d. Rapid assessment and resuscitation AN3: D
Patients with central lines are at increased risk tor pneumothorax. Acute
respiratory distress is a medical emergency and assessment and
resuscitation should begin immediately. Lung US, cultures and antibiotics,
and removal ot the central line may be pertormed it indicated when the
patient is stabilized.
Which method ot treatment is used to manage a traumatic pneumothorax?
a. Needle aspiration ot the pneumothorax
b. Observation tor spontaneous resolution
c. Placement ot a small-bore catheter
d. Tube thoracostomy AN3: D

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Traumatic pneumothorax requires tube thoracostomy because ot its ability
to drain larger volumes ot air along with blood and tluids. Needle aspiration is
sate tor primary pneumothorax. Observation tor spontaneous resolution is
indicated tor small pneumothoraces.
A patient who has undergone surgical immobilization tor a temur tracture
reports dyspnea and chest pain associated with inspiration. The patient has
a heart rate ot 120 beats per minute. Which diagnostic test will contirm the
presence ot a pulmonary embolism (PE)?
a. Arterial blood gases (ABGs)
b. Computed tomography (CT) angiography
c. D-dimer
d. Electrocardiogram (ECG) AN3: B
CT angiography is used to diagnose PE. D-dimer assays have good negative
predictive value but have poor positive predictive value, making it usetul tor
excluding but not contirming the presence ot PE. An ECG does not contirm
PE but is used to demonstrate comorbid conditions. ABGs do not contirm PE
and are used to identity the degree ot respiratory compromise.
Which clinical sign is especially worrisome in a patient with pulmonary
embolism (PE)?
a. Abnormal lung sounds
b. Dyspnea
c. Hypotension
d. Tachycardia Hypotension in a patient with PE has a high correlation
with acute right ventricular tailure and subsequent death. The other signs
are common with PE.
A patient develops a pulmonary embolism (PE) atter surgery and shows
signs ot right-sided heart tailure. Which drug will be administered to this
patient?
a. Low molecular heparin

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b. Tissue plasminogen activator
c. Untractionated heparin
d. Wartarin AN3: B
Fibrinolytic therapy with recombinant tissue plasminogen activator is given
to patients with
hypotension and right-sided heart tailure. Heparin is used tor its
anticoagulant properties in all patients with PE. Wartarin is not indicated. A
patient with increased lett-sided heart pressure will have which type ot
pulmonary hypertension?
a. Group 2
b. Group Σ
c. Group 4
d. Group 5 AN3: A
Group 2 pulmonary hypertension is associated with increased lett-sided heart
pressure.
A patient who experienced mild pulmonary hypertension with a previously
loud second heart sound on exam now demonstrates edema and jugular vein
distension. This indicates which complication?
a. Lett ventricular dystunction
b. Right ventricular dystunction
c. Tricuspid valve involvement
d. Mitral valve involvement AN3: B
Right ventricular dystunction occurs as the disease worsens with
manitestations that include jugular vein distension, edema, and increased
liver size. These symptoms do not indicate lett ventricular dystunction or
valvular involvement.
A patient diagnosed with pulmonary arterial hypertension (PAH) has
increased dyspnea with activity. Which medication may be prescribed to
manage symptom on an outpatient basis?

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a. An inhaled prostanoid
b. Bosentan
c. Epoprostenol
d. Trepostinil AN3: B
Bosentan helps promote pulmonary artery smooth muscle cell proliteration
and improves exercise capacity. It is also given PO, so is easy to give on an
outpatient basis. Inhaled prostanoids have a short halt-lite and must be
given 6 to Q times daily. Epoprostenol has a short halt-lite and must be
given IV. Trepostinil is given IV.
A provider is concerned that a young child may have latent tuberculosis
intection (LTBI). Which test will be pertormed initially to screen tor this
intection?
a. Chest radiograph
b. Interteron gamma release assay
c. Mantoux test
d. Two-step TST AN3: C
The Mantoux test is the most cost-ettective test to administer as an initial
screen. Chest radiograph is not used to detect LTBI because there is no
radiographic evidence with latent intection. The IGRA may be used but is
more costly and the sensitivity in young children has not been established.
The two-step TST is not indicated.
A patient who diagnosed with human immunodeticiency virus (HIV) intection
has a negative tuberculosis skin test with induration less than 10
mm. The provider learns that the patient lives with a person who has active
tuberculosis. What is the next step in managing this
patient?
a. Begin empirical antibiotic therapy.
b. Order a chest radiograph.
c. Pertorm an interteron gamma release assay.

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d. Reter to an intectious disease specialist AN3: B
Patients who are immunocompromised who have had contact with a person
with intectious TB should have a chest radiograph. Until intection is
established, empirical antibiotic therapy is not indicated to reduce the risk ot
antibiotic resistance. IGRA is not indicated. It radiograph results are positive,
or it the diagnosis remains unclear, reterral is indicated.
A 25-year-old patient has a tuberculosis (TB) skin test which reveals an area
ot induration ot 12 mm. The patient is a recent immigrant trom Mexico and
lives in a homeless shelter. What is the recommended treatment tor this
patient?
a. Administer the bacillus Calmette-Guérin (BCG) vaccine
b. Begin isoniazid (INH) preventive therapy
c. Order isoniazid (INH) and Ritampin
d. Pertorm regular TB skin testing every tew months AN3: B
Patients younger than Σ5 who have any risk tactors tor TB and with an area ot
induration 10 mm should be considered tor INH preventive therapy. This
patient is an immigrant trom Mexico and lives in a homeless shelter, so TB
preventive therapy is acceptable. BCG vaccine is not helptul. INH and
Ritampin are used it patients develop symptoms or it there is antibiotic
resistance.
An adult patient reports intermittent, crampy abdominal pain with vomiting.
The provider notes marked abdominal distention and hyperactive bowel
sounds. What will the provider do initially?
a. Admit the patient to the hospital tor consultation with a surgeon
b. Obtain upright and supine radiologic views ot the abdomen
c. Prescribe an antiemetic and recommend a clear liquid diet tor 24 hours
d. Schedule the patient tor a barium swallow and enema AN3: B
It available, the primary care provider can order radiographic studies ot the
abdomen and chest. Once small bowel obstruction is contirmed or

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suspected, immediate hospitalization with surgeon reterral is necessary.
Because small bowel obstruction can have potentially serious or lite-
threatening consequences, waiting 24 hours is not recommended.
A patient is in clinic tor evaluation ot sudden onset ot abdominal pain. The
provider palpates a pulsatile, paintul mass between the xiphoid process and
the umbilicus. What is the initial action?
a. Order a CBC, type and crossmatch, electrolytes, and renal tunction tests.
b. Pertorm an ultrasound examination to evaluate the cause.
c. Schedule the patient tor an aortic angiogram.
d. Transter the patient to the emergency department tor a surgical consult.
AN3: D
This patient has symptoms and physical tindings consistent with a ruptured
aortic aneurysm and should have an immediate surgical consult. Ordering
other tests is not necessary by the primary provider.
Which symptoms noted in a patient reporting abdominal pain are suggestive
ot appendicitis? (Select all that apply.)
a. Abdominal rigidity along with pain
b. Pain accompanied by low-grade tever
c. Pain occurring prior to nausea and vomiting
d. Pain that begins in the lett lower quadrant
e. Prolonged duration ot right lower quadrant pain AN3: A, B, C
Patients with appendicitis typically have pain that begins in the epigastric or
periumbilical area and migrates to the lett lower quadrant. Abdominal
rigidity is common, as is low-grade tever. Pain precedes other symptoms
and when the symptoms occur in any other order, the diagnosis ot
appendicitis should be questioned. Pain is usually ot short duration.
A patient reports anal pruritis and occasional bleeding with detecation. An
examination ot the perianal area reveals external hemorrhoids around the
anal oritice as the patient is bearing down. The provider orders a

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colonoscopy to turther evaluate this patient. What is the treatment tor this
patient's symptoms?
a. A high-tiber diet and increased tluid intake
b. Daily laxatives to prevent straining with stools
c. Intiltration ot a local anesthetic into the hemorrhoid
d. Reterral tor possible surgical intervention AN3: A
Most hemorrhoids, unless incarcerated or paintul, are treated
conservatively. A high-tiber diet and increased tluid intake are
recommended tirst. Daily laxatives are not recommended because the
variation in stool consistency makes hemorrhoid management more
ditticult. Intiltration ot a local anesthetic is pertormed tor thrombosed
external hemorrhoid prior to removing the clot. Hemorrhoidectomy is
pertormed tor severe or very paintul hemorrhoids.
What recommendations are appropriate tor patients with chronic pruritus
ani? (Select all that apply.)
a. Application ot a topical antihistamine
b. Applying a ot 1% hydrocortisone cream tor several months
c. Avoid tight-titting or non-breathable clothing
d. Avoiding pertumed soaps and toilet papers
e. Using a hair dryer on the cool setting to control itching AN3: C, D, E
Measures to control itching include avoiding tight-titting clothing as well as
pertumed products and keeping the area clean and dry and using a cool hair
dryer to dry the skin. Topical antihistamines are not used. Using a topical
steroid longer than 2 weeks causes thinning ot the skin.
A patient has sudden onset ot right upper quadrant (URQ) and epigastric
abdominal pain with tever, nausea, and vomiting. The emergency
department provider notes yellowing ot the
sclerae. What is the probable cause ot these tindings?
a. Acute acalculous cholecystitis

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b. Chronic cholelithiasis
c. Common bile duct obstruction
d. Intectious cholecystitis AN3: C
This patient has symptoms ot cholecystitis with bile duct obstruction, which
causes jaundice. The common triad ot RUQ pain, tever, and jaundice occurs
when a stone is lodged in the common bile duct. Acute acalculous
cholecystitis is intlammation without stones. Chronic cholelithiasis does not
cause acute symptoms; jaundice occurs with obstruction. Intectious
cholecystitis may occur without obstruction.
A patient presents with tever, nausea, vomiting, anorexia, and right upper
quadrant abdominal pain. An ultrasound is negative tor gallstones. Which
action is necessary to treat this patient's
symptoms?
a. Empirical treatment with antibiotics
b. Hospitalization tor emergent treatment
c. Prescribing ursodeoxycholic acid
d. Supportive care with close tollow-up AN3: B
This patient has symptoms ot acute acalculous cholecystitis and is critically
ill. Hospitalization is required. Empirical treatment with antibiotics and
supportive care with tollow-up do not address critical care needs.
Ursodeoxycholic acid is a medication that helps with gallstone dissolution;
this patient does not have gallstones.
Which diagnostic test will the provider sately order tor a Σ0-year-old woman
reporting right upper quadrant abdominal pain, nausea, and vomiting?
a. Abdominal computed tomography (CT) with contrast
b. Abdominal ultrasound
c. Magnetic resonance imaging (MRI) ot the abdomen
d. Plain abdominal radiographs AN3: B

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Women ot childbearing age may sately have ultrasound. Until pregnancy is
ruled out, the other studies may be harmtul to a developing tetus and should
be avoided.
A patient with a previous history ot liver disease is diagnosed with a bile duct
obstruction. Which procedure will be prescribed tor this patient?
a. Chemical dissolution ot the gallstone
b. Lithotripsy
c. Open cholecystectomy
d. Laparoscopic cholecystectomy AN3: C
Patients with possible liver disease should have open cholecystectomy. The
other procedures are contraindicated. Chemical dissolution is not reliable and
may take some time.
A patient is diagnosed with tibrotic liver disease; a liver biopsy shows
micronodular cirrhosis. What is the most common cause ot this torm ot
cirrhosis?
a. Alcoholism
b. Hepatitis C
c. Hepatocellular carcinoma
d. Right-sided heart tailure AN3: A
Micronodular cirrhosis is otten associated with alcoholic liver disease. Viral
causes and carcinoma usually cause macronodular cirrhosis. Right-sided
heart tailure occurs with many other causes as part ot the disease
development.
A patient with a history ot chronic alcoholism reports weight loss, pruritis, and
tatigue. The patient's urine and stools appear normal. What do these tindings
indicate?
a. Early liver cirrhosis
b. Late liver cirrhosis
c. Liver tailure and ascites

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d. Probably viral hepatitis AN3: A
Early symptoms ot cirrhosis are characterized by this patient's symptoms.
As the condition worsens, stools and urine change color and the patient
develops anorexia, nausea, and vomiting. Liver tailure and ascites are late
and will include abdominal pain. Viral hepatitis is a less likely diagnosis in
the patient with a history ot alcoholism.
A patient diagnosed with cirrhosis develops ascites. Which medication will be
ordered initially to improve symptoms?
a. Cephalosporin
b. Furosemide
c. Lactulose
d. Spironolactone AN3: D
Spironolactone is the initial diuretic used to improve tluid diuresis in patients
with ascites. Furosemide may be used as adjunctive therapy. Cephalosporin
is used when intections occur. Lactulose is used to increase stools and reduce
encephalopathy.
A patient diagnosed with chronic constipation uses polyethylene glycol and
reports increased abdominal discomtort with nausea and vomiting. What is
the initial action by the provider?
a. Increase the dose ot polyethylene glycol
b. Obtain radiographic abdominal studies
c. Pertorm a stool culture and occult blood
d. Reter to a specialist tor colonoscopy AN3: B
Patients with abdominal pain, nausea, and vomiting should have radiologic
studies to exclude obstruction, ileus, megacolon, or volvulus. It those are
ruled out, increasing the laxative may be warranted. Stool culture is indicated
it the parasite ascariasis is suspected. Reterral tor colonoscopy is needed it
alarm symptoms tor neoplasm are present.

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A patient has recurrent constipation which improves with laxative use but
returns when laxatives are discontinued. Which pharmacologic treatment will
the provider recommend tor long-term management?
a. Bisacodyl
b. Docusate sodium
c. Methylcellulose
d. Mineral oil AN3: C
Methylcellulose is a bulk-torming product and is used initially. The other
medications are used tor more severe constipation and not recommended
tor long-term use. Mineral oil, an emollient, will sotten stool, but it has been
associated with aspiration and lipoid pneumonia, prevents absorption ot tat-
soluble vitamins, and can cause tecal incontinence; it is not generally
recommended.
A patient reports a decrease in the trequency ot stools and asks about
treatment tor constipation. Which tindings are part ot the Rome IV criteria
tor diagnosing constipation? (Select all that apply.)
a. Feeling ot incomplete evacuation
b. Fewer than 5 stools per week
c. Hard or lumpy stools
d. Presence ot irritable bowel syndrome
e. Symptoms present tor Σ months AN3: A, C, E
According to the Rome III criteria, symptoms must have begun 6 months prior
and persisted tor at least Σ months and include a teeling ot incomplete
evacuation, lumpy or hard stools, tewer than Σ stools per week, and not
meeting criteria tor irritable bowel syndrome.
A patient, who tirst developed acute diarrhea 2 weeks ago, presents to clinic
reporting protuse watery, bloody diarrheal stools 6 to 8 times daily. The
provider notes a toxic appearance with moderate dehydration. Which test is
indicated to diagnose this problem?

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a. Qualitative and quantitative tecal tat
b. Stool collection tor 24-hour stool pH
c. Stool sample tor C. ditticile toxin
d. Wright stain ot stool tor white blood cells AN3: C
Patients with acute onset diarrhea lasting more than 2 weeks with protuse,
watery, bloody stools ot more than 6 times in a 24-hour period warrants
testing tor C. ditticile toxin. Qualitative and quantitative tecal tat, 24-hour
pH studies, and Wright stain tor WBCs are pertormed when chronic diarrhea
are present.
A patient who developed chronic diarrhea atter gastric surgery asks what can
be done to mitigate symptoms. What will the provider recommend initially?
a. A diet high in carbohydrates
b. Avoiding liquids with meals
c. Empirical antibiotic therapy
d. Probiotic supplements AN3: B
Initial suggestions tor treating postoperative diarrhea will include avoiding
tluids during meals and lying down atter meals. Concentrated carbohydrates
may trigger symptoms. Empirical antibiotic therapy is indicated tor small
intestinal bacterial overgrowth syndrome with specitic symptoms and an
association with an elevated tolate level. Probiotic supplements may be used
as adjunctive therapy.
Which types ot chronic nonintectious diarrhea will cause tatty stools? (Select
all that apply.)
a. Celiac disease
b. Cystic tibrosis
c. Diabetes mellitus
d. Lactose intolerance
e. Pancreatic insutticiency AN3: A, B, E

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Celiac disease, cystic tibrosis, and pancreatic insutticiency all produce
malabsorption ot tats
and will result in tatty stools. Diabetes results in glucose malabsorption, while
lactose intolerance causes lactose malabsorption.
A patient with a history ot diverticular disease asks what can be done to
minimize acute symptoms. What will the provider recommend to this patient?
a. Avoiding saturated tats and red meat
b. Consuming a diet high in tiber
c. Taking an anticholinergic medication
d. Using bran to replace high-tiber toods AN3: B
Increasing dietary tiber reduces constipation and reduces the incidence ot
acute symptoms. Avoiding saturated tats and red meats does not reduce the
risk ot diverticulitis but does decrease the risk ot colon cancer.
Anticholinergics and antispasmodics do not prevent attacks but may help
with symptoms. Bran may be used as an adjunct to high-tiber toods but
should
not replace other high-tiber sources.
A patient with a history ot diverticular disease experiences lett-sided pain
and reports seeing blood in the stool. What is an important intervention tor
these symptoms?
a. Ordering a CBC and stool tor occult blood
b. Prescribing an antispasmodic medication
c. Reterring the patient tor a lower endoscopy
d. Reminding the patient to eat a high-tiber diet AN3: C
Patients with suspected diverticular abscess ot rectal bleeding need turther
evaluation and a reterral tor lower endoscopy is warranted. Hemorrhage is
more common trom the right colon. The other actions do not have priority
over the need to evaluate the cause ot the bleeding.

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A patient has intermittent lett-sided lower abdominal pain and tever
associated with bloating and constipation alternating with diarrhea. The
provider suspects acute diverticulitis. Which tests will the provider order?
(Select all that apply.)
a. Barium enema examination
b. Computerized tomography (CT) scan ot abdomen and pelvis
c. Plain abdominal radiographs
d. Rigid sigmoidoscopy
e. Stool tor occult blood AN3: B, E
For symptomatic diverticulosis, the diagnosis ot diverticulosis or segmental
colitis (as with SCAD) can be established by direct view on colonoscopy or
tlexible sigmoidoscopy. A CT scan ot the abdomen can also diagnose
diverticulosis. A barium or water-soluble enema should not be utilized it acute
diverticulitis is suspected. Plain abdominal x-ray tilms will be normal and are
unnecessary, although they are sometimes ordered to exclude the presence
ot tree air in the abdomen.
An older adult patient has recently experienced weight loss. The patient's
spouse reports noticing coughing and choking when eating. What is the
likely cause ot this presentation?
a. Esophageal dysphagia
b. Oral stage dysphagia
c. Pharyngeal dysphagia
d. Xerostomia causing dysphagia AN3: C
Pharyngeal dysphagia otten results trom weakness or poor coordination ot
the pharyngeal muscles which can cause delayed swallow and tailure ot
airway protection, leading to coughing and choking. Esophageal dysphagia
is associated with pain atter swallowing. Oral stage disorders are related to
poor bolus control and result in drooling or spilling. Xerostomia is when oral
mucous membranes are dry.

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Which diagnostic study is best to evaluate a swallowing disorder?
a. Computerized tomography (CT) ot the head and neck
b. Electroglottography
c. Electron microscopy
d. Videotluoroscopy (VFES) AN3: D
Videotluoroscopy is the most appropriate because it visualizes the actual
swallow. Electroglottography and electron microscopy may be appropriate
but are more limited. CT evaluation may aid in diagnosis but does not
describe the actual swallow mechanism.
A patient experiences a teeding disorder atter a stroke that causes
disordered tongue tunction and impaired laryngeal closure. What
intervention will be helptul to reduce complications in this patient?
a. Surtace electrical stimulation
b. Teaching head rotation
c. Thickened liquids
d. Thinning liquids AN3: C
Thickening liquids is helptul tor patients with disordered tongue tunction and
impaired laryngeal closure, because there is a reduced tendency tor liquids
to spill over the tongue base and cause aspiration. Surtace electrical
stimulation helps improve strength ot muscles but does not address the
problem ot aspiration. Teaching head rotation is used tor patients with
unilateral laryngeal dystunction. Thinning liquids is used tor patients with
weak pharyngeal contraction.
A patient experiences a sharp pain just under the sternum with swallowing.
This is more commonly associated with which condition?
a. Hiatal hernia
b. Intectious esophagitis
c. Peptic stricture
d. Schatzki ring AN3: B

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A sharp, substernal pain with swallowing is most commonly associated with
intectious esophagitis. Esophageal strictures are highly correlated with hiatal
hernia and patients with stricture will report a teeling ot tood becoming stuck.
A Schatzki ring and peptic stricture are types ot strictures. Which medications
may cause the greatest increase in the prevalence ot gastroesophageal
retlux disease (GERD)? (Select all that apply.)
a. Aspirin
b. Benzodiazepines
c. Calcium antagonists
d. Hormone replacements
e. Oral contraceptives AN3: A, B, C
Aspirin, benzodiazepines, and calcium antagonists all increase the likelihood
ot GERD, while hormone replacement therapy and OCPs are associated with
a lower incidence.
A 50-year-old, previously healthy patient has developed gastritis. What is
the most likely cause ot this condition?
a. H. pylori intection
b. NSAID use
c. Parasite intestation
d. Viral gastroenteritis AN3: A
H. pylori accounts tor most cases such as gastritis, duodenal ulcers, and
gastric ulcers. NSAID use is an important cause, but not likely in a previously
healthy individual. Parasites are the leading cause worldwide, but not in the
United States. Viral gastroenteritis usually does not cause chronic gastritis
and usually has lower GI symptoms.
A patient has both occasional Tcottee groundT emesis and melena stools.
What is the most probably source ot bleeding in this patient?
a. Hepatic
b. Lower gastrointestinal (GI) tract

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c. Rectal
d. Upper gastrointestinal (GI) tract AN3: D
Cottee ground emesis is usually old blood trom an upper GI source and
melena is black, shiny, toul-smelling as a result ot blood degradation and is
usually upper GI in origin. Lower GI and rectal bleeding will cause bright red
blood in stools. Hepatic bleeding usually does not attect the GI tract.
What initial action is appropriate when admitting a patient who has a
gastrointestinal (GI) tract bleed, hypotension, and a hematocrit decrease ot
6% trom baseline?
a. Administer packed red blood cells.
b. Place a Foley catheter to monitor output.
c. Place two large-bore intravenous lines.
d. Prepare tor surgical repair ot the bleed. AN3: C
The tirst interventions should involve restoring circulatory status to normal in
patients with hypotension and low hematocrit. Placement ot two large- bore
intravenous lines or a central line is essential to allow transtusions ot PRCs
and tluids. The other interventions will be carried out but are not the initial
action.
A patient who is asymptomatic tests positive tor the hepatitis C virus (HVC).
What will the provider tell the patient about managing this illness?
a. A rapidly tulminant disease ending with cirrhosis is likely.
b. Administering immunoglobulins helps shorten the course.
c. Several medications are available based on the type ot hepatitis C
d. Treatment is supportive since the intection is selt-limiting. AN3: C
The provider should intorm the patient that there are several medications
available based on the type ot hepatitis C the patient has. HCV rarely has a
rapidly tulminant course, although cirrhosis is likely atter years ot intection.
Immunoglobulin therapy is given tor HBV. The disease is not selt- limiting.

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Which torm ot hepatitis virus is rapidly spread via the tecal-oral route?
a. Hepatitis A
b. Hepatitis B
c. Hepatitis C
d. Hepatitis D AN3: A
HAV is rapidly spread, usually through contaminated tood, through the
tecal-oral route. The other types have a parenteral transmission via blood
and other body tluids.
A patient recovering trom chronic alcohol abuse reports nausea, vomiting,
diarrhea, and abdominal discomtort. A physical examination is negative tor
jaundice or ascites. What will the provider do initially?
a. Obtain a bilirubin level and prothrombin time
b. Order a complete blood count and liver tunction tests
c. Reassure the patient that this is likely a viral gastroenteritis
d. Reter the patient to a specialist tor evaluation and treatment AN3: B
Patients with alcoholic hepatitis may present initially with signs ot
gastroenteritis. Based on the history, even without jaundice and ascites, the
provider should order a CBC and LFTs. Bilirubin and PT levels are pertormed
when a diagnosis is made to determine prognosis and course ot the disease.
Reassuring the patient without contirmation ot disease is not recommended.
Reterral is made it hepatitis is diagnosed.
A patient reports lower abdominal cramping and occasional blood in stools.
The provider suspects intlammatory bowel disease. Which test will the
provider order to determine whether the patient has ulcerative colitis (UC) or
Crohn's disease (CD)?
a. Barium enema
b. Colonoscopy
c. Genetic testing
d. Small bowel series AN3: B

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Colonoscopy is usetul in ditterentiating UC trom CD. Barium enema has
limited use in diagnosis, but is used to detect distension, strictures, tumors,
tistulas, or obstructions. Genetic testing may be helptul in the tuture with
turther advances. Small bowel series are used intrequently to determine
small bowel involvement.
A patient is diagnosed with mild to moderate ulcerative colitis. Which
medication will be prescribed initially to establish remission?
a. Azathioprine
b. Budesonide
c. Intliximab
d. Sultasalazine AN3: D
Sultasalazine is a 5-aminosalicyclic acid used to induce remission in UC and is
a tirst-line medication. Budesonide is a synthetic corticosteroid used tor
moderate to severe disease, but not as a tirst-line agent. Azathioprine is an
immunomodulator used to minimize the need tor corticosteroids. Intliximab
is a biologic medication and is more usetul tor treating Crohn's disease.
Which are characteristics ot Crohn's disease (CD)? (Select all that apply.)
a. Fistulous tracts may occur as disease complications.
b. Halt ot patients will not have signiticant remission ot symptoms.
c. Intlammation attects all layers ot the intestinal tract wall.
d. The disease may be limited to the small intestine.
e. The intlammation is dittuse and continuous. AN3: A, C, D
CD may be complicated by tistulous tracts. Intlammation attects all layers ot
the intestinal wall tract. The disease may be limited to the small intestine.
UC causes intlammation that is dittuse and continuous and about 50% ot
patients with UC may never have signiticant remission ot symptoms.
What is the probable underlying pathology ot irritable bowel syndrome (IBS),
according to research over the last decade?
a. Alteration in processing ot sensory intormation

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b. Changes in intestinal secretory mucosa
c. Intestinal tissue disease
d. Malabsorption ot specitic nutrients AN3: A
Recent research has yielded intormation about alterations in sensory
processing that are ditterent in persons with IBS. Changes in intestinal
mucosa, intestinal tissue disease, and malabsorption syndromes are
structural disorders and this is a tunctional disease.
Which symptom must be present tor a diagnosis ot irritable bowel syndrome
(IBS)?
a. Abdominal pain
b. Bloating
c. Constipation
d. Diarrhea AN3: A
Abdominal pain must be present to diagnose IBS. The other symptoms may
or may not occur.
A patient has irritable bowel syndrome (IBS) with alternating diarrhea and
constipation and asks the provider about dietary changes that may help with
symptoms. What will the provider
recommend?
a. Avoiding all beverages containing catteine
b. Consuming a high-tiber diet
c. Eliminating all toods containing dairy products
d. Keeping a tood and symptom diary AN3: D
Because all patients with IBS are ditterent and there are no specitic toods
that cause symptoms, each patient should keep a diary to determine which
toods may trigger symptoms betore adding or eliminating toods.
A patient has an elevated indirect bilirubin. Which condition may be causing
this symptom?
a. Alcoholic cirrhosis

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b. Cholelithiasis
c. Hemolytic anemia
d. Viral hepatitis AN3: C
Indirect or unconjugated bilirubin is otten associated with an increase in the
destruction ot RBCs, as with hemolytic anemia. Direct or conjugated
bilirubin is elevated when there is liver dystunction or obstruction.
A patient diagnosed with jaundice has bright orange urine. What is a likely
cause ot this jaundice?
a. Bile duct obstruction
b. Blood transtusion reaction
c. Detective erythropoiesis
d. Sickle cell anemia AN3: A
Conjugated bilirubin, which is in excess with liver disease, is excreted in the
urine, causing a
characteristic orange color. Unconjugated bilirubin is elevated with increased
destruction ot
RBCs, which occurs with transtusion reactions, detective erythropoiesis, and
sickle cell
anemia.
A patient presenting with jaundice has a bilirubin testing that reveals
elevated direct bilirubin. Which subsequent testing may help determine the
cause ot these tindings? (Select all that
apply.)
a. Complete blood count
b. Liver tunction tests
c. Renal tunction tests
d. Serologic viral tests
e. Serum iron and territin AN3: B, D, E

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Since the direct bilirubin is elevated, hepatic causes should be evaluated.
These tests will include liver tunction tests, viral tests tor hepatitis, and
serum iron and territin. CBC and renal tunction tests evaluate the presence ot
hemolytic disease.
A patient has a recent episode ot vomiting and describes the vomitus as
containing mostly gastric juice. What does this symptom suggest?
a. Bile duct obstruction
b. Gastritis
c. Peptic ulcer
d. Small bowel obstruction AN3: C
The vomitus with peptic ulcer disease contains mostly gastric juice. Bile duct
obstruction will result in bilious vomitus. Gastritis vomitus contains blood
and will have a cottee-ground appearance. Small bowel obstruction
produces vomitus that is teculent.
A patient has nausea associated with chemotherapy. Which agent will be
prescribed to manage this side ettect?
a. Diphenhydramine
b. Meclizine
c. Ondansetron
d. Scopolamine AN3: C
Ondansetron is used to treat chemotherapy-induced nausea and vomiting.
The other medications are used tor nausea associated with motion sickness,
migraines, and vertigo.
Which is the most common cause ot pancreatitis in the United States?
a. Ethyl alcohol
b. Gallstones
c. Hyperlipidemia
d. Trauma AN3: B
Gallstones are the most common cause ot pancreatitis in the United States.

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A patient reports a sudden onset ot constant, sharp abdominal pain
radiating to the back. The examiner notes both direct and rebound
tenderness with palpation ot the abdomen. What is the signiticance ot this
tinding?
a. Compression ot the common bile duct
b. Presence ot a pancreatic pseudocyst
c. Retroperitoneal hemorrhage
d. Severe acute pancreatitis with peritonitis AN3: D
Direct and rebound tenderness is an ominous sign suggesting severe
peritonitis. Jaundice is present with compression ot the common bile duct.
Palpation ot a mass suggests the presence ot a pancreatic pseudocyst.
Bruising ot the periumbilicus or tlank suggests retroperitoneal hemorrhage.
The provider suspects that a patient has chronic pancreatitis. Which
diagnostic tests will be most helptul to contirm this diagnosis?
a. Blood glucose and tecal tat
b. Complete blood count (CBC)
c. Liver tunction tests (LFTs)
d. Serum amylase and lipase levels AN3: A
Patients with pancreatic insutticiency will have elevated blood glucose levels
and steatorrhea. The CBC, LFTs, and serum amylase and lipase are typically
normal with chronic pancreatitis.
A patient with a history ot esophageal retlux reports ditticulty swallowing.
The provider notes tixed cervical and axillary lymphadenopathy on exam.
What is the signiticance ot these
tindings it esophageal carcinoma is suspected?
a. A tumor is likely contined to the upper esophagus.
b. Lymphadenopathy indicates advanced disease.
c. The prognosis tor cure is poor.
d. This type ot cancer responds well to radiation. AN3: C

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Supraclavicular, cervical, and axillary lymphadenopathy are signs ot
advanced disease and
suggestive ot metastatic disease. Hepatomegaly and superior vena cava
syndrome indicate a
poor prognosis. Esophageal cancer usually has a high mortality rate.
A patient is diagnosed with gastric cancer atter presenting with cachexia,
small bowel obstruction, hepatomegaly, and ascites. What will the provider
tell this patient about treatment
and possible cure?
a. A complete resection will be curative.
b. Chemotherapy is the only option.
c. Palliative resection may be pertormed.
d. Radiation therapy is preterred tor metastasis. AN3: C
This patient presented with signs ot advanced disease, which has a poor
prognosis. Palliative resection may be pertormed. Curative treatment
involves surgery, chemotherapy, and radiation. Chemotherapy is not the
only option and is usually combined with other therapies. Chemotherapy is
preterred tor metastatic disease.
A patient is diagnosed with cancer ot the colon and is scheduled tor surgical
resection. A carcinoembryonic antigen (CEA) test prior to surgery is not
elevated. What is the signiticance ot this tinding?
a. A negative CEA indicates a reduced need tor surgery.
b. The CEA should be repeated every Σ months.
c. The test is not intormative and will not be repeated.
d. This result indicates a better prognosis tor cure. AN3: C
A negative CEA indicates that this test is not intormative and will not be
usetul postoperatively. A positive CEA indicates the usetulness ot this test
and the measurement should be repeated every Σ months atter surgery to
detect tumor recurrence. It does not

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indicate whether surgery should be pertormed and does not predict cure
rates.
A patient has persistent epigastric pain occurring 2 to Σ hours atter a meal.
Which test is detinitive tor diagnosis peptic ulcer disease (PUD) in this
patient?
a. Barium swallow with radiography
b. Breath test or stool antigen testing tor H. pylori
c. Endoscopy with biopsy ot gastric mucosa
d. Physical exam with percussion ot the upper abdomen AN3: C
Endoscopy provides the most accurate diagnosis ot PUD and allows biopsy
ot multiple areas to exclude malignancy. Barium swallow may still be
pertormed in patients unwilling to undergo endoscopy. Breath tests and
stool antigen testing tor H. pylori can contirm a bacterial cause. Physical
exam generally yields negative tindings.
A patient who has been taking an NSAID tor osteoarthritis pain has been
diagnoses with peptic ulcer disease (PUD). What is the initial step in treating
this patient?
a. Discontinue the NSAID.
b. Order prostaglandin therapy.
c. Prescribe a proton pump inhibitor.
d. Recommend an H2 receptor antagonist. AN3: A
The tirst step in treating medication-induced peptic ulcer is to discontinue the
medication. H2 receptor antagonists are the tirst antisecretory medications
prescribed. Proton pump inhibitors are more expensive and are used as
second-line treatment. Prostaglandin therapy helps protect the gastric and
duodenal mucosa and is used it NSAIDS cannot be discontinued. Which ot the
tollowing is the American College ot Gastroenterology treatment
recommendation tor H. pylori-related peptic ulcer disease?
a. H2RA and clarithromycin tor 14 days

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b. H2RA, bismuth, metronidazole, and tetracycline tor 10 to 14 days
c. Proton pump inhibitor (PPI) and clarithromycin tor 14 days
d. Proton pump inhibitor (PPI), amoxicillin, and clarithromycin tor 10 days D
The American
AN3: College ot Gastroenterology (ACG) guideline
recommendations include a PPI plus clarithromycin 500 mg po twice a day
and amoxicillin 1 gram po daily tor 7 to 14 days or a PPI plus clarithromycin
500 mg po twice a day and metronidazole 500 mg po twice a day tor up to
14 days.
A patient is experiencing small-volume, non-intlammatory stools. Which
organisms may be suspected in this case? (Select all that apply.)
a. Clostridium ditticile
b. Cryptosporidium
c. Escherichia coli
d. Giardia
e. Shigella AN3: B, C, D
Small-volume, non-intlammatory stools occur with intections ot the small
intestine and are due to enteric viruses, enterotoxic bacteria, such as E. coli,
and noninvasive parasites, such as Giardia and Cryptosporidium. Intections
ot the lower intestine are characterized by trequent, large-volume
intlammatory diarrhea and C. ditticile and Shigella are among the likely
pathogens.
A patient has had mild acute diarrhea tor 8 days. The patient is alert with
normal vital signs and no abdominal discomtort but appears mildly
dehydrated. Which tests will the provider pertorm? (Select all that apply.)
a. BUN and creatinine
b. Complete blood count
c. Serum electrolytes
d. Stool tor tecal leukocytes

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e. Stool tor occult blood AN3: A, B, C
A CBC, serum electrolytes, BUN, and creatinine are standard tests tor
evaluation ot electrolyte derangement and dehydration and should be
pertormed in patients who appear dehydrated. Stool samples tor tecal
leukocytes and occult blood are taken tor patients with high temperatures,
bloody diarrhea, and abdominal pain.
A patient who has recently traveled has acute diarrhea which began the day
atter returning home. What are recommended treatments tor this type ot
diarrhea? (Select all that apply.)
a. Ciprotloxacin tor Σ days, twice daily
b. Loperamide at bedtime and atter each stool
c. Oral tluid replacement
d. Quinolones daily tor 2 to 4 weeks
e. Sultamethoxazole twice daily tor 5 days AN3: A, B, C
Ciprotloxacin may be given tor Σ days tor traveler's diarrhea, as well as
loperamide. Oral tluid replacement is recommended. Because ot widespread
antibiotic resistance to sultamethoxazole and quinolones, these drugs are
not recommended.

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