Download NR 509 Midterm Exam Review Questions,Answers with Rationales(LATEST, 2024) :Chamberlain and more Exercises Nursing in PDF only on Docsity!
Pg 83
It is also important to ask about the presence or absence of additional symptoms or other relevant
information—such as risk factors for coronary artery disease in patients with chest pain, or current
medications in patients with syncope—that may help you generate a list of possible causes
(differential diagnosis) to explain the patient’s problem or condition. This list will include the most
likely and, at times, the most serious causes, even if less likely. When clinicians obtain a history,
they are continually generating possible explanations in their minds, allowing the patient’s answers
to direct the logical use of additional probing questions. This process of probing with questions is
similar to testing a hypothesis. With each question, the list of probable diagnoses (or hypotheses) is
pared down until a few likely choices are left from a formerly longer list of diagnostic possibilities.
Pg 503
Upper back pain, neck or gaw pain, SOB; paroxysmal nocturnal dyspnea; N&V = careful history taking
is especially important
Atypical symptoms are particularly seen in woman esp if over the age of 65
NR 509 Midterm Exam Review
1. Which of the following statements best describes a differential diagnosis list?
A. It is a list of planned interventions for the problems assessed during the visit.
B.It is the list of concerns brought to the appointment by the patient.
C.It is a list of different diagnoses experienced by the patient in the past.
D.It is a list of potential/plausible diagnoses that may be causing the patient’s signs
and symptoms. E.It is a list of diagnoses that have already been ruled out as causes
for the chief complaint.
2. A 66-year-old female presents to the primary care office with complaints of jaw pain, fatigue, and nausea
for the last 48 hours. What course of action is appropriate in the treatment of this patient?
A. Refer the patient to an otolaryngologist to evaluate for jaw pain.
B. Prescribe the medication for the jaw pain and nausea and reevaluate in 2-3 days.
C. Order x-rays of the jaw and abdomen to further evaluate.
D. Recognize these could be atypical symptoms of acute coronary syndrome and proceed
accordingly.
E. Order screening blood work to evaluate for thyroid disease.
3. In an adult over the age of 40, an S3 assessment finding on cardiac auscultation may be indicative of
what? Select all that apply.
A. anemia
B. myocardial
infarction C. heart
failure pg 551
D. normal for athletes - pg 522
E. ventricular volume overload from aortic or mitral regurgitation - pg 551
Pg 551
Pathologic S3 or ventricular gallop sounds like a physiological S3 - in adult over 40 is usually
pathologic, arising from high left ventricular filling pressures and abrupt deceleration of inflow across
the mitral valve at the end of the rapid filling phase of diastole. Causes include decreased
myocardial contractility, heart failure, and ventricular volume overload from aortic or mitral
regurgitation and left to right shunts
Pg 548 MI can cause soft S1; pg 495 MI causes pathological ventricular stiffness which marks an S
heart sound right before the S1 (also heard in HTN)
Pg 1049
Chronic Anemia and following exercise can cause pulmonary flow murmurs - in the presence of volume
Pg 427 this scenario is detailed with - these findings suggest pharyngitis or mild tonsillitis
Pg 1018 Tonsillar abscess - a peritonsillar abscess is suggested by erythema and asymmetric
protrusion of one tonsil, pain, difficulty opening mouth (trismus), and lateral displacement of the
uvula.
Pg 427 Asymmetry tonsils particularly when associated with other symptoms, may signify and
underlying pathology such as lymphoma
Pg 432 - infectious mononucleosis - enlarged posterior cervical lymph nodes (or general
lymphadenopathy pg 345); fatigue pg 212; pg 1047 an adolescent with persistent fever, sore throat,
swollen tonsils and cervical lympadenopathy may have streptococcal pharyngitis or infectious
mononucleosis
Pg 402 - Upper respiratory infection - Is nasal or sinus congestion preceded by a viral upper
respiratory tract infection? Is there purulent nasal discharge, loss of smell, tooth pain, facial pain
made worse by bending forward, ear pressure, cough or fever? - Acute bacterial sinusitis
(rhinosinusitis) is unlikely until viral URI symptoms persist more than 7 days; both purulent drainage
and facial pain should be present for diagnosis (sensitivity and specificity are above 50%) if nasal
This scenario is detailed on page 262 - these findings suggest depression
Pg 245 - Anxiety - common risk factors in patient with anxiety and related disorders include family
history of anxiety
6. A 14-year-old male presents to the clinic with his grandmother for a complaint of a sore throat. The
patient is afebrile and denies cough. After completing the history and physical examination, the NP
documented the following partial assessment findings:
Throat—Oral mucosa pink, dental caries in lower molars, tongue midline, uvula, and pharynx
erythematous, bilateral tonsils enlarged, no exudates.
Neck—Trachea midline. Neck supple; thyroid isthmus midline, lobes palpable but not enlarged.
Lymph Nodes—Submandibular and anterior cervical lymph nodes tender, 1 cm × 1 cm, rubbery and
mobile; no posterior cervical, epitrochlear, axillary, or inguinal lymphadenopathy.
Which of the following is the most accurate interpretation of the findings?
A. These findings suggest pharyngitis.
B. These findings suggest tonsillar abscess.
C. These findings suggest lymphoma.
D. These findings suggest mononucleosis.
E. These findings suggest upper respiratory illness.
7. The NP is assuming care for a 56-year-old female resident of a long-term assisted living facility. The
woman is seated in a wheelchair next to a window in her private room. After completing the history and
physical examination, the NP documented the following mental status findings:
The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled.
Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented
to person, place, and time. Digit span, serial 7s, and calculations accurate, but responses delayed.
Clock drawing is good.
Which of the following is the most accurate interpretation of the findings?
A. These findings suggest depression.
B. These findings suggest anxiety.
C. These findings suggest mood disorder.
D. These findings suggest a neurocognitive disorder.
E. These findings suggest intellectual disability.
COPD - unable to speak more than two or three words at a time due to shortness of breath. He has
intercostal muscle retraction when breathing and sits upright in bed. He is thin, with diffuse muscle
wasting. Height is 6 ft 2 in; weight, 175 lb; BP, 160/95, right arm; HR, 108 and irregular; RR, 32 and
labored; temperature, 101.2°F.”
Pneumonia - pg 87 fever and cough - hx of smoking - rhinorrhea, asymmetric chest wall excursion
and dullness to chest w/ percussion p 145; exudates seen on c ray; pleuritic pain with deep
inspiration pg 448; sputum often green with bacterial pneumonia pg 450
Asthma - pg 483 WH pg 455 retraction occurs in severe asthma
Chronic bronchitis - pg 477 - chronic cough; sputum mucoid to purulent, may be blood-streaked or
even bloody - often recurrent WH and dyspnea and prolonged hx of tobacco
Left-side HF - rales or crackles ( pg 462); orthopnea and PND pg 504; increase JVP (508)
personal history of anxiety or mood disorder, childhood stressful life events or trauma, being female,
chronic medical illness and behavioral inhibition.
Pg 247 Anxiety is often comorbid with substance use and mood disorders
Pg 250 Sudden-onset memory problems are concerning for major vascular neurocognitive disorders,
wherein vascular occlusion damages structures important for memory. Rapid-onset memory
problems after a head injury should raise suspicion for a major neurocognitive disorder due to TBI.
delirium and dementia fall under neurocognitive disorders pg 249; mini mental is best known
screening for dementia pg 264
Intellectual disability - poor scoring in constructional ability (daw these simple shapes) pg 261; poor
abstract thinking
- ask what a proverb means (don’t count your chickens before they hatch) pg 261; impaired recent
memory pg 260; poor performance in serial 7s pg 259; digit span - poor performance at - repeat #
8. The NP conducted a physical assessment on a 74-year-old male with a complaint of shortness of breath.
His history is significant for a 20 pack-year history of smoking. He uses 2 inhalers daily (medication
unknown) but did not bring them with him to his appointment. The documentation for the respiratory findings
is as follows:
Which of the following is the most accurate interpretation of the findings?
A. These findings suggest COPD. - total guess (2 inhalers - smoker? - makes me think emphysema
not list)
B. These findings suggest pneumonia.
C. These findings suggest asthma.
D. These findings suggest chronic bronchitis.
E. These findings suggest left-sided heart failure.
9. A 28-year-old female presents to the office for an annual physical examination. The NP is evaluating
the cranial nerves (CNs) while assessing the eyes. The findings are represented in this image. Damage or
inflammation of which of the following cranial nerve(s) is demonstrated in this image?
ADA Description: Eyes looking right and looking left.
A. CN II
B. CN III somewhat of a guess
C. CN IV
D. CN V
E. CN VI
neck and upper chest
Cannot do without photo
Pertinent negatives - pg 86 - note absence of symptoms r/t differential dx = expected symptoms or
signs that are not present, facts that you expect to find if a possible cause for a patient’s problem
were true - which weakens dx
There was no fever, cough with sputum production, chest pain, nausea or vomiting. He has no prior
history of coronary artery disease or anxiety.”
Historical information that may be possible causes of shortness of breath to consider in this example
is lung infections (fever, cough with sputum production), heart attack (history of coronary artery
disease, chest pain), and anxiety. = pertinent positives
especially the negatives clarify the possible causes of the patient’s condition as well as eliminate
other less likely possibilities based on the patient’s story.
Page 7 - When asking patients about their pronouns, it can be helpful to share your own pronouns with
patients, asking: “Which gender pronouns do you use?” (Box 1-3). For example, “I use... he and
him/she and hers/they and theirs.” Some of your patients may use nontraditional pronouns.
Page 504 - Orthopnea and PND occur in left ventricular heart failure and mitral stenosis and also in
obstructive lung disease.
E. scattered, erythematous round drop-like, flat-topped well-circumscribed scaling papules on
the left anterior neck that does not cross the midline
12. An NP is caring for a patient with depression. The patient reports not feeling suicidal although still
depressed on their current regimen of medication. Documenting the lack of suicidal ideation is an example
of what important aspect of clinical documentation?
A. including pertinent negatives
B. including sufficient detail to support the diagnosis and plan
C. including pertinent positives
D. keeping a neutral and professional tone
E. establishing a problem list
13. The NP is establishing rapport with a patient during an initial encounter and prepares to ask the patient
how they would like to be addressed. What additional consideration should the NP acknowledge when
asking patients about their pronouns?
A. Patients will likely feel uncomfortable with gender identification questions.
B. When asking patients about their own pronouns, it can be helpful to share your own.
C. Addressing patients using depersonalized names can avoid conflict or uncomfortable
feelings during the clinical encounter.
D. Children are less likely to share how they prefer to be addressed.
E. You should select the pronoun that best matched the person’s physical appearance.
14. Orthopnea and paroxysmal nocturnal dyspnea (PND) generally occur in the following conditions?
Select all that apply.
A. left ventricular heart
failure B. mitral stenosis
C. obstructive lung disease
D. pulmonary embolus
E. spontaneous pneumothorax
17. A 42-year-old male complains of pain in his left leg. He does not remember injuring his leg; however, he
notes that there is a small wound on the lateral aspect of his mid-shin. Upon examination, some mild
erythema surrounding the wound and flat, nonpalpable red streaks progressing up his leg are noted. What
do these streaks likely represent?
A. thrombus formation in a
superficial vein B. draining lymphatic
channels - unsure
C. dilated arterioles
D. dilated veins secondary to incompetent valves
E. occluded arterial vessels
Sounds like pt has more then one thing causing issue… So focusing on the streaks I think it is likely
Acute Lymphangitis = red streatks on the skin with tenderness, enlarged, tender lymph nodes and
fever- caused by acute infection usually from staph, spread up the lymphatic channels from distal
portal of entry such as skin abrasion, ulcer or dog bite (pg 587)
Pg 574 - Calf asymmetry >3 cm increases the LR for DVT to >2.20 Also consider muscle tear or trauma,
Baker cyst (posterior knee), and muscular atrophy.
Local swelling, redness, warmth, and a subcutaneous cord signal superficial thrombophlebitis, an
emerging risk factor for DVT.22 Asymmetric warmth and redness over the calf signal cellulitis.
Unilateral calf and ankle swelling, and edema suggest venous thromboembolism (VTE) from DVT,
chronic venous insufficiency from prior DVT, or incompetent venous valves; or it may be
lymphedema. If you detect unilateral swelling or edema, measure the calves 10 cm below the tibial
tuberosity. Bilateral edema is present in heart failure, cirrhosis, and nephrotic syndrome. Venous
distention suggests a venous cause of edema.
Rationale: Acute lymphangitis is typically caused from an acute bacterial infection of the skin that
causes red streaks from distal drainage through the lymphatic system. The streaks are typically flat,
not palpable cords as found in thrombus formation in a superficial vein. Dilated veins also are not flat.
Occluded arterial vessels are not superficial or visible. Dilated arterioles are still too small to be
visible at the skin surface.
18. A 61-year-old female was recently diagnosed with ovarian cancer. She has not been feeling well lately
and presents to the clinic with a cough and some mild shortness of breath for the past couple of days as
well as worsening pain and swelling in her right groin and leg for about a week. On physical examination, 2+
edema of the right leg up to the thigh; 1+ femoral, popliteal, dorsalis pedis, and posterior tibial pulses; and
no significant erythema are noted. Based on the history and symptomatology, the NP should consider which
high-risk differential diagnosis?
A. acute lymphangitis
B. ovarian
metastasis C.
pulmonary embolism
D. acute arterial occlusion
Pg 148 - Pulmonary embolism is likely as the patient has shortness of breath & unilateral leg
swelling also tachy and hx of long fight can be pertinent
Pg 477 - PE = dry cough or hemoptysis - associated symptoms = Tachypnea, chest or pleuritic
pain, dyspnea, fever, syncope, anxiety; factors that predispose to deep venous thrombosis.
Rationale: Cancer patients are at high risk of deep venous thrombosis (DVT), and, with the
presenting symptoms of swelling and pain in her groin, along with recent history of cough and
shortness of breath, this patient’s presentation is suspicious for PE. Patients with DVT in the proximal
leg veins are at high risk of thromboembolism. Acute arterial occlusion should not cause significant
edema, and pulses would likely be absent. The constellation of symptoms and history in this patient
also does not suggest an acute arterial occlusion. Superficial thrombophlebitis typically only causes
mild local swelling, redness, and warmth along with a subcutaneous cord. Acute lymphangitis
typically presents with red streaks from an infection passing through lymph channels.
E. superficial thrombophlebitis
Pg 507 - Although the JVP accurately predicts elevations in fluid volume in heart failure, its
prognostic value for heart failure outcomes and mortality is unclear.
Rationale: This patient is in heart failure based upon the symptoms and physical examination
findings. The murmur is consistent with tricuspid regurgitation that may be the result of ventricular
dilation and failure of the valve to completely close. Symptoms often improve with diuresis. Based
upon the examination, the murmur is not consistent with underlying mitral or aortic valve disease.
Although the blood pressure is high, it is not high enough to cause this degree of symptomatology. A
ventricular septal defect is a holosystolic murmur heard within the left third to fifth interspaces, but is
often associated with a thrill.
Pg 549 - Wide physiologic splitting of S2 refers to an increase in the usual splitting of S2 during
inspiration that persists throughout the respiratory cycle. Wide splitting is caused by delayed closure
of the pulmonic valve (as in pulmonic stenosis or right bundle branch block ) or early closure of the
aortic valve (mitral regurgitation). Right bundle branch block is illustrated here.
Rationale: Patients with an atrial septal defect often experience dyspnea as well as atrial
arrhythmias. Fixed splitting of the second heart sound occurs in atrial septal defects and right heart
failure and does not vary with respiration. A left bundle branch block causes paradoxical splitting
secondary to the delayed closure of the aortic valve. Wide splitting of the second heart sound is
secondary to a delayed closure of the pulmonic valve and is often found in right bundle branch
blocks and pulmonic stenosis. Tricuspid stenosis would not usually affect the second heart sound as
it is a component of S1.
Pg 569 - If the pain is relieved by sitting and bending forward, or if there is bilateral buttock or leg
pain, the etiology is more likely to be spinal stenosis
Rationale: Neurogenic claudication can mimic PAD by causing pain related to walking; however, it is
typically relieved simply by sitting or by leaning forward. Many patients with spinal stenosis of the
lumbar spine have pain that originates in the spinal region and radiates into the areas noted. PAD is
not typically relieved just by sitting alone and usually will take some time. PAD also does not
typically improve with bending over. Acute arterial occlusion does not cause recurring symptoms
and is not usually bilateral. Abdominal aortic aneurysms may cause similar pain as well; however,
they typically do not have the same palliating factors.
22. A 70-year-old male presents with progressive shortness of breath and two-pillow orthopnea. On physical
examination, the blood pressure is 145/90 mm Hg, there is jugular venous distension, lower extremity pitting
edema to the knee, and a blowing holosystolic murmur heard best at the lower left sternal border. No other
murmurs or thrills are auscultated on the physical exam. Which of the following interventions is most likely
to improve the patient’s symptoms?
A. decrease in blood pressure
B. removal of intravascular volume with diuresis
C. replacement of the mitral valve
D. replacement of the aortic valve
E. repair of a ventricular septal defect
23. A 21-year-old male is experiencing dyspnea on exertion and palpitations. On cardiac auscultation,
the second heart sound is split and fixed on both inspiration and expiration. What is the most likely
cardiac condition associated with this finding?
A. right bundle branch
block B. atrial septal
defect
C. tricuspid stenosis
D. left bundle branch block
E. pulmonic stenosis
Pg 521 - Listen for splitting of this sound in the second and third left intercostal spaces. Ask the
patient to breathe quietly and then slightly more deeply than normal.
Rationale: The pulmonic area is the left second and third interspace close to the sternum. The mitral
area is at the apex. The right second interspace overlies the aortic valve. The tricuspid space is the
lower left sternal border. The midsternum does not correspond to the anatomic location of any of
the four cardiac valves; however, it is important to remember that murmurs radiate and must be
interpreted in the setting of the clinical scenario.
Rationale: Patients with aortic stenosis often experience dyspnea with exertion, chest pain, or
dizziness. The calcification of the aortic valve and narrowing of the valve area effectively decreases
the blood flow from the left ventricle to the aorta. Given the obstruction created from the narrowing
of the aortic valve, the pressure within the left ventricle is often higher than that seen in the aorta.
Aortic insufficiency is associated with blood flow from the aorta to the left ventricle during diastole
and is often not associated with differences in systolic blood pressure. Mitral stenosis involves
narrowing of the valve between the left atrium and left ventricle while mitral regurgitation involves
the flow of blood from the left ventricle to the left atrium during systole when the mitral valve is
normally closed.
Rationale: Pulmonary hypertension may arise from underlying lung disease from smoking such as
emphysema or chronic obstructive pulmonary disease. Pulmonary hypertension often results in right
ventricular hypertrophy. Aortic stenosis, hypertrophic cardiomyopathy, and hypertension all cause
left ventricular hypertrophy and would displace the point of maximal impulse (PMI) lateral to the
midclavicular line. Mitral regurgitation is often not associated with ventricular hypertrophy.
24. An NP student is examining a patient with a structurally normal heart. The student is having difficulty
auscultating the splitting of the second heart sound. At what area on the patient’s chest would the
student have the best opportunity of hearing this sound?
A. first intercostal space at the lower left sternal border
B. fifth intercostal space at the midclavicular line
C. apex
D. second intercostal space at the right sternal border
E. second and third intercostal space at the left sternal border
25. A 77-year-old male is experiencing progressive shortness of breath and dizziness. The patient undergoes
cardiac catheterization, and the systolic blood pressure measured in the left ventricle is 180 mm Hg, while
the systolic blood pressure measured in the aorta is 140 mm Hg. The patient is most likely experiencing
symptoms related to what valve condition?
A. aortic insufficiency
B. mitral regurgitation
C. pulmonic
stenosis D. aortic
stenosis
E. mitral stenosis
26. An 89-year-old female with a history of smoking two packs of cigarettes a day for 50 years complains to
her NP of progressive shortness of breath. On cardiac examination, the NP finds the most prominent
palpable impulse to be in the xiphoid area. This is most likely a result of what condition?
A. pulmonary hypertension
B. aortic stenosis
C. mitral regurgitation
D. hypertrophic cardiomyopathy
E. hypertension
Rationale: Pectus excavatum is a congenital abnormality in which the inferior part of the sternum is
displaced inward. Barrel chest is incorrect. In a barrel chest there is an increased anteroposterior
diameter. A barrel chest often accompanies chronic obstructive pulmonary disease. Flail chest is
incorrect. The injured area of a flail chest moves inward with inspiration and moves outward with
expiration. Pigeon chest is incorrect. Pigeon chest, also known as pectus carinatum, is a congenital
abnormality in which the sternum is displaced anteriorly. Thoracic kyphoscoliosis is incorrect.
Thoracic kyphoscoliosis is characterized by abnormal spinal curvatures and vertebral rotation, which
are visible posteriorly (rather than anteriorly).
Rationale: Strike using the tip of the third finger is a part of good technique for percussing the lungs
and some other structures in the body. The proximal interphalangeal joint is the joint that is struck is
incorrect. It is the distal interphalangeal joint that is struck in good percussion technique. Press the
third and fourth fingers next to each other on the chest is incorrect. Only the third finger is pressed
against the chest in good percussion technique.
Strike using the finger pad of the fourth finger is incorrect. It is the tip of the third finger that is used
in good percussion technique. The wrist is kept still during percussion is incorrect. A direct brisk yet
relaxed wrist movement is used in good percussion technique.
Rationale: Wheezes are suggestive of narrowed airways, as in asthma, chronic obstructive pulmonary
disease, or bronchitis. Mediastinal crunch is incorrect. A mediastinal crunch is suggestive of
pneumomediastinum, not asthma. Pleural rub is incorrect. A pleural rub can be suggestive of a pleural
effusion or a pneumothorax, not asthma.
Rhonchi are incorrect. Rhonchi are suggestive of secretions in larger airways, not asthma.
Stridor is incorrect. Stridor is suggestive of partial obstruction of the larynx or trachea, not
29. A 29-year-old male presents to the clinic with a cough for 2 months. When he lowers his gown so the
NP can listen to his lungs, the NP notices a depression of the lower part of his sternum. Which of the
following best describes the appearance of his chest?
A. flail chest
B. pectus excavatum
C. thoracic kyphoscoliosis
D. barrel chest
E. pigeon chest
30. An NP is percussing the lungs of a patient with chronic obstructive pulmonary disease (COPD)
for resonance. Which of the following is an example of good percussion technique?
A. The wrist is kept still during percussion.
B. Strike using the finger pad of the fourth finger.
C. The proximal interphalangeal joint is the joint that
is struck. D. Strike using the tip of the third finger.
E. Put the third and fourth fingers next to each other on the chest.
31. An 18-year-old male presents to the clinic for a 3-month history of periodic dyspnea when playing
basketball. It resolves shortly after resting. He has not had a fever, chills, cough, sputum production, or
chest pain. He has no history of serious illness. Based on the history, asthma is suspected. Which of the
following sounds heard on expiration during lung auscultation would be most suggestive of asthma?
A. stridor
B.
wheezes
C. rhonchi
D. mediastinal crunch
E. pleural rub
32. A 74-year-old female patient presents with a complaint of palpitations. While checking her pulse, you
notice an irregular rhythm. During auscultation, you note every fourth beat sounds different. It sounds like
a triplet rather than the usual “lub dub.” How would you document your examination findings?
A. regular rate and rhythm
B. irregularly irregular
rhythm C. regularly
irregular rhythm
D. supraventricular tachycardia
E. sporadic arrhythmia
This sounds like trigeminy to me - on chart below document as “regularly irregular” pg 539-
33. Regarding the eyes, which of the following physical assessment findings are expected as part of
the normal aging process?
A. blurring of near vision
B. superficial grayish-white discoloration of the cornea
C. opacity of the lenses visible through the pupil
D. thickening of the bulbar conjunctiva
Blurring of near vision - pg 365 Testing near vision with a handheld card can help identify the need
for reading glasses (bifocals or progressive lenses) in patients older than 45 years. You can also use
this card to test visual acuity at the bedside. Held 14 inches from the patient’s eyes, the card
simulates a Snellen chart.
Presbyopia causes focusing problems for near vision, found in middle-aged and older adults.
A person with presbyopia often sees better when the card is farther away.
Google “What are normal age-related vision changes?
As you age, it is normal to notice changes in your vision. A few common changes for older adults
include: Losing the ability to see up close. Having trouble distinguishing colors, such as blue from
black.”
Pg 387 - Corneal Arcus. A thin grayish-white arc or circle not quite at the edge of the cornea.
Accompanies normal aging but also seen in younger adults, especially African Americans. In young
adults, suggests possible hyperlipoproteinemia. Usually benign.
Pg 394 Drusen are yellowish round spots that vary from tiny to small. The edges may be soft, as
here, or hard (p. 377). They are haphazardly distributed but may concentrate at the posterior pole
between the optic disc and the macula. Drusen consist of dead retinal pigment epithelial cells. Seen
34. An 81-year-old male presents to the vascular clinic with a painful sore on his right leg. On examination,
the NP notes an ulcerative lesion near the medial malleolus with accompanying hyperpigmentation. Which
of the following etiologies is most likely associated with these assessment findings?
A. arterial insufficiency
B. neuropathic
ulcer C. venous
insufficiency
D. trauma
E. superficial phlebitis
Pg 589 - Arterial - This condition occurs in the toes, feet, or possibly areas of trauma (e.g., the shins).
Surrounding skin shows no callus or excess pigment, although it may be atrophic. Pain often is
severe unless masked by neuropathy. May be accompanied by gangrene, along with decreased
pulses, trophic changes, foot pallor on elevation, and dusky rubor on dependency.
Pg 589- Neuropathic Ulcer -This condition develops in pressure points of areas with diminished
sensation; seen in diabetic neuropathy, neurologic disorders, and Hansen disease. The surrounding
skin is calloused. There is no pain, so the ulcer may go unnoticed. In uncomplicated cases, there is
no gangrene. Associated signs include decreased sensation and absent ankle jerks.
Pg 589 Chronic Venous Insufficiency- This condition usually appears over the medial and sometimes the
lateral malleolus. The ulcer contains small, painful granulation tissue and fibrin; necrosis or exposed
tendons are rare.
Borders are irregular, flat, or slightly steep. Pain affects quality of life in 75% of patients. Associated
findings include edema, reddish pigmentation and purpura, venous varicosities, the eczematous
changes of stasis dermatitis (redness, scaling, and pruritus), and at times cyanosis of the foot when
dependent. Gangrene is rare.
Pg 584 - Superficial phlebitis - involves inflammation of superficial vein at times venous thrombosis -
confirmed by imaging; pain and tenderness along superficial vein (most often saphenous system);
causes = immobility venous stasis, chronic venous disease, venous procedures- local induration,
erythema - if palpable nodules or cords consider superficial or deep vein thrombosis, both associated
with risk of DVT and PE
35. A 61-year-old female presents with the complaint of cough for 1 week. She is a smoker. The
pulmonary examination revealed positive egophony with E-to-A change in the left lower lobe and crackles
on auscultation. These assessment findings are strongly indicative of what etiology?
A. lobar pneumonia
B. pleural effusion
C. chronic bronchitis
D. emphysema
E. asthma
