Assignment: D, a 20 yo nursing student presents to the student wellness center with complaints of fatigue, rhinitis, and a cough for 2 weeks. The cough is productive of small amounts of sputum. The patient has a negative health history, is not on any prescription medications, and denies a history of allergies. Physical examination reveals a temperature of 100°F, respirations of 16 breaths/min, and pulse of 96 beats/min. Lung examination reveals fine crackles on the left lower lobe of the lung. A chest radiograph (x-ray) shows diffuse infiltrates on the same lobe. What is the diagnosis most likely to be?
Assignment: D, a 20 yo nursing student presents to the student wellness center with complaints of fatigue, rhinitis, and a cough for 2 weeks. The cough is productive of small amounts of sputum. The patient has a negative health history, is not on any prescription medications, and denies a history of allergies. Physical examination reveals a temperature of 100°F, respirations of 16 breaths/min, and pulse of 96 beats/min. Lung examination reveals fine crackles on the left lower lobe of the lung. A chest radiograph (x-ray) shows diffuse infiltrates on the same lobe. What is the diagnosis most likely to be?
Answer Rationale Exam #1
Name_____________________________________ Date_____________________
Utilizing diagnostic reasoning, identify the correct answer and provide evidence-based rationale for why it is correct. Rationales should be based on most current literature and guidelines and be substantive. Sources of information must be cited.
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- D, a 20 yo nursing student presents to the student wellness center with complaints of fatigue, rhinitis, and a cough for 2 weeks. The cough is productive of small amounts of sputum. The patient has a negative health history, is not on any prescription medications, and denies a history of allergies. Physical examination reveals a temperature of 100°F, respirations of 16 breaths/min, and pulse of 96 beats/min. Lung examination reveals fine crackles on the left lower lobe of the lung. A chest radiograph (x-ray) shows diffuse infiltrates on the same lobe. What is the diagnosis most likely to be?
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- Streptococcus pneumonia
- Mycoplasma pneumonia
- Allergic rhinitis
- Legionnaire’s disease
- The CURB-65 Severity Score estimates mortality of CAP to help determine inpatient vs. outpatient treatment. The R in CURB stands for:
- respiratory rate.
- rapid pulse rate.
- recent use of antibiotics.
- During the history portion of a respiratory assessment, it is particularly important to ask if the client takes which of the following drugs?
- Beta-2 agonists
- Calcium channel blockers
- Angiotensin-converting enzyme (ACE) inhibitors
- Birth control pills
Questions 4-9
According to the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, which of the following is the most appropriate antimicrobial for treatment of CAP in:
- A 42-year-old man with no comorbidity, no reported drug allergy, and no recent antimicrobial use?
- oral doxycycline
- oral cefpodoxime
- oral TMP-SMX
- oral ciprofloxacin
- A 46-year-old well woman with a history of a bilateral tubal ligation who is macrolide intolerant?
- oral clarithromycin
- oral cephalexin
- oral doxycycline
- oral Fosfomycin
- A 78-year-old woman with a history of COPD, hypertension, and dyslipidemia who is taking lovastatin and a dihydropyridine calcium channel blocker?
- oral clindamycin
- oral amoxicillin-clavulanate with oral doxycycline
- oral clarithromycin
- IM ceftriaxone
- A 69-year-old man with heart failure, prior myocardial infarction, and type 2 diabetes?
- oral respiratory fluoroquinolone
- oral amoxicillin with clavulanate
- oral cephalosporin
- oral TMP-SMX
- A 28-year-old woman with a severe beta-lactam allergy who has a dry cough, headache, malaise, and no comorbidity who takes no medication?
- oral clarithromycin
- oral amoxicillin
- IV levofloxacin
- IM ceftriaxone
- A 47-year-old woman who was recently hospitalized and given parenteral antimicrobials for diverticulitis?
- oral amoxicillin-clavulanate
- high-dose oral amoxicillin
- oral clarithromycin
- oral moxifloxacin
- A 24-year-old nursing student presents to the student health center with complaints of persistent asthma. What should the first-line treatment for this patient be?
- Inhaled corticosteroids (ICS)
- Long-acting beta2-agonists (LABAs)
- Leukotriene inhibitors
- Short-acting beta2-agonists (SABAs)
- When asthma does not respond to traditional therapy, it may be due to another syndrome that mimics asthma, such as:
- lower airway obstruction.
- upper airway obstruction.
- What is the preferred reliever medication for asthmatics according to the Global Initiative for Asthma (GINA, 2020) treatment guideline?
- Low-dose ICS with formoterol
- SABA
- LABA
- Leukotriene receptor antagonist
- Which statement about chronic obstructive pulmonary disease (COPD) is true?
- The prevalence of COPD is directly related to increasing age.
- The incidence of COPD is about equal in men and in women.
- Cigar or pipe smoking does not increase the risk of developing COPD.
- Environmental factors such as smoke do not affect the potential for COPD.
- A 50-year-old male smoker with COPD presents to the clinic complaining of several days of fever, loss of appetite, coughing, and chest pain. The cough is productive of purulent sputum. Physical examination reveals a temperature of 102.0°F, pulse of 88, respiratory rate of 24. The lung exam reveals crackles on the lower right lobe and wheezing on the upper airways. Which of the following bacteria is more likely to be the infectious agent?
- Streptococcus pneumoniae and Mycoplasma pneumoniae
- Staphylococcus aureus and Mycoplasma pneumoniae
- Haemophilus influenzae and Streptococcus pneumoniae
- Legionella pneumophilia and Haemophilus influenzae
- What is the preferred treatment for the above patient’s condition?
- Amoxicillin
- Doxycycline
- Amoxicillin-clavulanate (Augmentin) plus a macrolide
- Azithromycin (Z-Pak) plus a fluoroquinolone
- Other than smoking cessation, which of the following most slows the progression of COPD in smokers?
- Making sure the environment is free of all pollutants
- Eliminating all pets from the environment
- Engaging in moderate to high levels of physical activity
- Remaining indoors with air conditioning as much as possible
- The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines recommend antibiotic therapy for patients who have an exacerbation with increased sputum volume. Which antibiotic increases the risk ofClostridium difficile infection?
- Amoxicillin-clavulanate
- A macrolide
- A fluoroquinolone
- A cephalosporin
- When used in treating COPD, ipratropium bromide (Atrovent®) is prescribed to achieve which of the following therapeutic effects?
- increase mucociliary clearance
- reduce alveolar volume
- bronchodilation
- mucolytic action
- Which is most consistent with the diagnosis of COPD?
- FEV1:FVC ratio equal to or less than 0.70 after properly timed SABA use
- dyspnea on exhalation
- elevated diaphragms noted on x-ray
- polycythemia noted on complete blood cell count
- Evidence-based practice has shown that clients with COPD will benefit the most from which of the following single modalities?
- Nutritional supplementation
- Routine use of inspiratory muscle training
- Pulmonary rehabilitation
- Psychosocial interventions
Questions 21-24. Indicate whether each statement is True or False.
- Seasonal influenza vaccination is recommended for household members of people with COPD.
- A 66-year-old woman with COPD ideally should receive an influenza vaccine specifically developed for use in older adults.
- People with COPD should not receive the pneumococcal vaccine until 65 years of age.
- A 52-year-old immunocompetent patient with COPD who receives the pneumococcal polysaccharide 23 vaccine (PPSV 23, Pneumovax) should get revaccinated in 5 years.
- Julie, age 30, is healthy and asks you when she should be screened for tuberculosis.
- Every year
- Every other year
- At age 1 year, again at entry to preschool or kindergarten, and then at some point during adolescence
- Screening is not necessary.
- Marci, age 24, is getting ready to go into nursing school. She is required
to be tested for TB. She is foreign born and had the Calmette-Guerin (BCG)
vaccine during infancy. What do you do to test her for TB?
- You perform a Mantoux TST (tuberculin skin test) and then repeat it if it is positive
- You order a chest x-ray.
- You do a history and physical, and if Marci is healthy, no further action is needed. You would sign a waiver for the TB test.
- You perform an interferon-gamma release assay (IGRA).
- Maria, aged 24, is pregnant and has tuberculosis. Which of the following
medications commonly prescribed for tuberculosis would you NOT prescribe for
her?
- Isoniazid (INH)
- Rifampin (RIF)
- Pyrazinamide (PZA)
- Ethambutol (EMB)
- A 33-year-old woman works in a small office with a man recently diagnosed with
active pulmonary TB. Which of the following would be the best plan of care for
this woman?
- She should receive TB chemoprophylaxis if her TST result is 5 mm or more in induration.
- Because of her age, TB chemoprophylaxis is contraindicated even in the presence of a positive TST result.
- If the TST result is positive but the chest radiograph is normal, no further evaluation or treatment is needed.
- Further evaluation is needed only if the TST result is 15 mm or more in induration.
- For a patient suspected of active pulmonary TB disease, which of the following approaches is least helpful in confirming the diagnosis?
- chest radiograph
- Gram stain from blood sample
- acid-fast microscopy from sputum sample
- culture and susceptibility from sputum sample
- The definitive test for sleep apnea is
- a Holter monitor.
- a trial period of a continuous positive air pressure (CPAP) appliance.
- an overnight polysomnogram.
- an ear, nose, and throat specialist confirming an abnormal uvula.
Bonus Questions (1 point for each correct answer)
Which of the following is the most frequent contributor to the incidence of carcinoma of the lung?
- Chronic pneumonia
- Exposure to materials such as asbestos, uranium, and radon
- Chronic interstitial lung disease
- Cigarette smoking
Symptoms of lung cancer caused by a primary tumor include all of the following except:
- chest discomfort.
According to ACCP guidelines, annual screening with LDCT for lung cancer should occur in 55- to 77-year-old smokers with a smoking history of at least________pack-years.
- 15
- 30
- 50
- 70