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NR 601 Final Exam Marking Scheme(A+) .
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NR 601 Final Exam MarkingScheme(A+)
An 86-year-old female comes to your office for a wellness visit. Her blood pressure is
125/70 mmHg, pulse 69 beats per min, and respiratory rate 18 breaths per min. She is
well appearing and reports she is up to date on her routine vaccinations. She introduces
her partner of 35 years whom she would like to make medical decisions for her in case
she becomes unable to make decisions for herself. She reports that she and her partner
are not married. She asks if she needs any further documentation to ensure her goals of
care are followed. Which one of the following would be the most appropriate
recommendation for this patient and her partner? - ANS-Advise them to file an
advanced directive.
. An 81-year-old transgender female with history of depression and hyperlipidemia
presents to your clinic for routine care. She endorses a history of smoking, currently
smoking 1 pack per day, and occasionally drinks a glass of wine, although she denies
illicit drug use. She reports she takes atorvastatin 20 mg and subcutaneous estrogen
therapy. - ANS-Counseling on smoking cessation
An 84-year-old male with history of stroke without residual deficit, systolic heart failure,
and type 2 diabetes presents to clinic for follow-up. He is independently living in a
retirement community and still works part time on a golf course. He currently takes
aspirin 81 mg, metoprolol tartrate 25 mg BID (twice a day), furosemide 20 mg BID, and
lisinopril 10 mg daily. He reports his last colonoscopy was 8 years ago, with no
abnormality. He reports he is sexually active with men and women, engaging in
receptive oral, receptive anal, and penetrative sex. He states he has had over three
sexual partners in the last year with intermittent condom use. What sexually transmitted
infection testing should be offered? - ANS-Urine testing, blood testing, anal swab, and
oropharyngeal swab
Which of the following is true about tolterodine? - ANS-It has greater risk of adverse
effects with its twice-daily formulation.
An 82-year-old man, Mr. A, complains of worsening nocturia, occurring four times per
night. His other lower urinary tract symptoms are slow stream, occasional urgency, and
urgency-related leakage once weekly. Medical problems include poorly controlled
hypertension, diastolic heart failure, hyperlipidemia, osteoarthritis, and prediabetes. His
,medications include lisinopril 20 mg daily, metoprolol succinate 75 mg daily,
atorvastatin
10 mg daily, metformin 500 mg twice daily, hydrocodone-acetaminophen as needed,
and aspirin 81 mg daily. Amlodipine 5 mg daily was recently added by his cardiologist.
On review of systems, Mr. A complains that nocturia is causing daytime fatigue, and he
is more constipated. Physical examination is notable for blood pressure 162/83 mmHg,
heart rate 60 beats per minute, clear lungs, soft abdomen, enlarged prostate, and 21
pretibial edema. Your next step in management should be: - ANS-Stop amlodipine and
increase lisinopril.
The daughter of a 79-year-old woman notes that her mother, who has dementia and
lives with her, is wetting herself when she attends her new day program. Program staff
have requested that "something be done" as she is requiring a clothes change nearly
every time she is there. She cannot describe the circumstances of leakage, saying "it
just comes." Leakage is uncommon at home. Her medications include donepezil and
acetaminophen. Physical examination is normal. Initial treatment approach will require
intervention by which of the following? - ANS-Day program staff
. Ms. J, who is 82 years old, complains of urine leakage while playing golf. This has
gotten worse over the past year, and she rarely makes it through nine holes without
feeling like she needs to "run into the bushes and go." Leakage is usually small volume,
but causes her extreme embarrassment because she is afraid she will smell of urine.
She has tried limiting caffeine in the morning before she golfs and avoiding drinking
water while playing, to no effect. She also tried "those Kegler" exercises in the past
without success. Which of the following is the most appropriate recommendation for Ms.
J? - ANS-Bladder training
What is the most common cause of erectile dysfunction in older men? -
ANS-Atherosclerosis
Which is the most reasonable first step in the treatment of older men with erectile
dysfunction? - ANS-Sildenafil
A 72-year-old woman reports vaginal dryness that interferes with coitus. Her medical
history includes type 2 diabetes, hypertension, and osteoarthritis. Medications are
glyburide, chlorthalidone, and acetaminophen. What would be your first step in therapy?
- ANS-Stop chlorthalidone
A 70-year-old woman reports sexual pain with deep penetration only. What is the most
, likely cause of her problem? - ANS-High-tone pelvic floor dysfunction
A 79-year-old woman with a 1.5-cm breast cancer underwent lumpectomy. Pathology
revealed ductal carcinoma that is hormone receptor negative (estrogen receptor 0%,
progesterone receptor 1%) and HER2/neu negative. Surgical margins were adequate
and uninvolved with cancer. Sentinel lymph node sampling was negative for lymph node
involvement. She has good performance status and no activities of daily living (ADL) or
instrumental (IADL) dependencies. What treatment would you recommend? -
ANS-Hormonal therapy only
An 86-year-old man with no ADL deficits who has stopped driving because of macular
degeneration is evaluated for a urinary tract infection associated with urinary retention.
The consulting urologist places a Foley catheter and sends a prostate-specific antigen
(PSA) level that comes back 12 ng/mL. Three months later after the Foley has been
removed and he has had a good response to tamsulosin, his PSA is still 10 ng/mL.
What is the appropriate next step in managing this man's prostate problem? -
ANS-Repeat PSA in 6 months
In which of the following patients is chemical or surgical castration likely to prolong
survival? - ANS-A 78-year-old man who had a radical prostatectomy and external beam
radiation therapy 10 years earlier now has a PSA level of 24.5 ng/mL. A CT scan of the
pelvis shows an enlarged pelvic lymph node, and a bone scan is positive in the pelvis.
On admission to the hospital, an 85-year-old woman was found to have a fungating
mass on her right breast. The mass is 9 cm in diameter, partially ulcerated, and
associated with edema of the arm and obvious pain. The patient has no children and
had lived alone until recently, when a neighbor became concerned for what appeared to
be a progressive loss of memory and neglect of the house. A nephew living in another
city eventually came to take care of the situation and arranged for the admission. The
patient appears confused and withdrawn; her appearance is disheveled, but she seems
to be independent in her ADLs. The medical history is negative for any serious
illnesses. She was able to drive her own car until shortly before this admission. The
nephew does not wish to authorize hospice "right now." A positron-emission
tomography scan was negative for metastatic disease. In addition to determining the
cause of her delirium, which of the following is the best way to address the breast
mass? - ANS-The mass should be biopsied to study hormone receptor and HER2/neu
antigen status.
A 78-year-old man has an emergency partial colectomy for lower gastrointestinal
bleeding. A localized colonic adenocarcinoma is completely resected. The surgeon did
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