NR511 MIDTERM QUESTION BANK (SOLVED)
Q bank questions Respiratory
An adult has upper respiratory symptoms and cough for the past 14 days. What should be
... [Show More] considered? (Pertussis)
Pertussis should always be considered in adults who present with acute cough of greater than 5 days’ duration. The incubation period for pertussis is about 7-10 days. Patients present with URI symptoms for 1-2 weeks. The classic paroxysmal cough usually begins in the second week of the illness. The duration of symptoms and cough are about 3 months even when treated with antibiotics. This is highly infectious and is a reportable disease.
Mycoplasma pneumoniae is: (a disease with extrapulmonary manifestations)
Mycoplasma is an atypical pathogen and produces atypical pneumonia. It can be difficult to diagnose because symptoms can be varied and involve multiple body systems (extrapulmonary manifestations). Infection with Mycoplasma may present with a normal white blood cell count, maculopapular rash, GI symptoms, tender joints and aches, and, though rare, cardiac rhythm disturbances. Respiratory symptoms may not be pronounced. On chest X-ray there are some unique findings (peribronchial pattern) with Mycoplasma. These include thickened bronchial shadow, streaks of interstitial infiltration, and atelectasis. These are more likely to occur in the lower lobes.
Which medication below is contraindicated in an asthma patient because it may increase risk of sudden death if used alone? (Long-acting bronchodilator)
A long-acting bronchodilator can be used to treat asthma when it is used in combination with an inhaled steroid. Otherwise, using a long-acting bronchodilator like salmeterol is contraindicated. There is an increased risk of sudden death with asthma exacerbations when this class is used solo to treat asthma. The other choices can be used to treat asthma. Choices vary depending on the patient.
A 75-year-old female with emphysema who has been treated with inhaled steroids for many years should: (should be screened for osteoporosis)
Older females are at higher risk than others for osteoporosis. This female patient, who has used inhaled steroids and smokes, has multiple risk factors for osteoporosis. Additionally, she probably has emphysema because she smoked (or still smokes). If she is Asian or Caucasian, she has still another risk factor. Screening for osteoporosis should be considered when managing patients with multiple risk factors.
A patient received the pneumonia immunization at age 60 years. He is 65 years old and presents to your clinic today. What recommendation should be made about the pneumococcal immunization? (He should receive another one today)
This patient should receive another one today because he is 65 years old and at least 5 years has elapsed since his last one. The CDC does not recommend immunizing this patient every 5 years. Two immunizations are available, PCV13 and PPSV23. He needs both, but PCV13 should be administered today. PPSV23 should be administered at least 1 year later.Which of the following medications should be used cautiously in a patient who has asthma? (Timolol
ophthalmic drops)
Timolol is a beta blocker. This class of medications can precipitate bronchoconstriction in patients who
have asthma. Even though timolol is being administered in the eye, it is absorbed through mucous
membranes and can exert systemic effects. Beta blockers should be avoided in patients with asthma and
used cautiously in patients with COPD. The other medications listed have no specific contraindications
for patients with asthma.
The most common symptom associated with acute bronchitis is: (Cough)
Fever (temp > 101°F) is an unusual symptom associated with acute bronchitis. Cough is the most
common symptom associated with acute bronchitis. Purulent sputum is identified in more than 50% of
patients with acute bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial
cells, not bacterial infection. Concurrent upper respiratory symptoms are typical of acute bronchitis.
Pharyngitis is common.
Mild persistent asthma is characterized by: (symptoms occurring more than twice weekly)
Mild persistent asthma is characterized by symptoms that occur more than twice weekly but not daily; or
3-4 nocturnal awakenings per month due to asthma. It is treated with an inhaled steroid daily, and a
bronchodilator PRN for exacerbations. If symptoms occur more than twice weekly, therapy should be
stepped up. Generally, a long-acting bronchodilator is added to the steroid when therapy is stepped up.
The chest circumference of a 12 month-old is: (equal to head circumference)
The chest circumference is not routinely measured at well-child visits, but is assessed if there is concern
about the circumference of either the head or the chest. An exception to this observation can occur in
premature infants where the head grows very rapidly. Normally, the head exceeds the chest
circumference by 1-2 cm from birth until 6 months. Between 6 and 24 months the head and chest
circumference should be about equal and by 2 years of age the chest should be larger than the head. The
chest circumference is measured at the nipple line.
A patient with cough and fever is found to have infiltrates on chest x-ray. What is his likely diagnosis?
(Pneumonia)
The finding of infiltrates on chest x-ray, in conjunction with clinical findings of fever and cough, should
direct the examiner to consider pneumonia as the diagnosis. Other common clinical findings with
pneumonia include chest pain, dyspnea, and sputum production. Though not common, some patients
with pneumonia exhibit gastrointestinal symptoms like nausea, vomiting, and diarrhea.
An uncommon symptom associated with acute bronchitis is: (temperature > 101°F)
Fever is an unusual symptom associated with acute bronchitis. Cough is the most common symptom
associated with acute bronchitis. Purulent sputum is identified in more than 50% of patients with acute
bronchitis. The color imparted to the sputum is usually due to sloughing of epithelial cells, not bacterial
infection. Concurrent upper respiratory symptoms are typical of acute bronchitis. Pharyngitis is common
within the first 3 days of the illness.
Patients who have cough-variant asthma: (all exhibit cough)One of the most common causes of cough in adults is asthma. Cough due to asthma is often
accompanied by episodic wheezing or dyspnea, though some patients who have asthma only cough. This
is termed “cough-variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of
the airways is a typical finding.
The most common cause of atypical pneumonia in adults is: (Mycoplasma pneumonia)
In patients who have atypical pneumonia, Mycoplasma is the most common pathogen. M. pneumoniae
is so named because of its atypical appearance on chest X-ray. This organism is responsible for “walking
pneumonia” that is prevalent in a young adult population. This accounts for about 15% of pneumonia
and is transmitted via respiratory droplet.
Which patient might be expected to have the worst FEV1? (A 65-year-old with emphysema)
FEV 1 stands for “forced expiratory volume in 1 second.” This is the volume of air that is forcefully
exhaled in the first second of exhalation after a deep breath. Patients with emphysema are not able to
do this efficiently because their alveoli are stretched, and mostly contain trapped air. FEV 1 is used to
assess airway obstruction. An asthma patient in the green zone would be expected to have a normal
(compared to himself) FEV1. An FEV1 measurement or pulmonary function tests would not be
performed on a patient with pneumonia or bronchiectasis because he would have diminished
respiratory capacity related to his infection.
A patient who has asthma presents with chest tightness, wheezing, coughing, and fever. He has
wheezing and diminished breath sounds in the upper right lobe. His cough is nonproductive, and he
denies nasal symptoms. Which symptom is not likely related to his asthma? (Fever)
Wheezing is typical of asthma, but one must consider pneumonia in any patient who presents with
diminished breath sounds in only one lobe. Fever is not typical of asthma or an exacerbation.
Ipratropium is very widely used in the treatment of COPD. Which of the following statements about
ipratropium is correct? (It decreases parasympathetic tone and produces bronchodilation)
Ipratropium is the most widely studied anticholinergic medication used to treat patients with COPD. It
produces its helpful effects by reducing cholinergic tone in the lungs. It may be used with a beta agonist
if shortness of breath is present. However, beta agonists increase side effects like tachycardia and tremor
and do not improve efficacy.An 80-year-old has Stage 3 COPD. He is most likely to have concomitant: (anxiety or depression)
About 40% of older patients who have COPD have concomitant anxiety and/or depression. It should be
treated because it affects the overall management of COPD. COPD is characterized by airflow limitation
and dyspnea. This may contribute to feelings of chronic anxiety. Additionally, many chronic diseases are
associated with depression. This is the case with COPD.
A 6-year-old child who has moderate persistent asthma is diagnosed with pneumonia after chest X-ray
and laboratory studies. He developed a sudden onset of fever with chills. He is in no distress. What is
the preferred treatment for him? (Amoxicillin)
In children who are older than 5 years of age, the most common bacterial pathogen is an atypical
pathogen. Because this child has asthma and uses an inhaled steroid daily, the most likely pathogen is
Streptococcus pneumoniae. An abrupt onset of fever and chills is suggestive of Streptococcal
pneumonia. Amoxicillin is usually chosen first for its efficacy, cost, and tolerability. The higher dose (80-
100 mg/kg/d) is chosen because of the prevalence of resistant Streptococcus pneumoniae. Azithromycin
would be chosen if an atypical pathogen was more likely. Doxycycline is not an appropriate choice
because it has poor Strep coverage and it is contraindicated in children younger than 8 years.
What disease is usually managed with a short-acting or long-acting inhaled anticholinergic
medication? (COPD)
First-line treatment for patients with COPD who have intermittent symptoms of shortness of breath is an
anticholinergic medication because it improves lung function. Alternatively, a short-acting beta agonist
may be used. Anticholinergic medications are not used as a lone agents to manage symptoms of asthma;
inhaled steroids usually are. Bronchitis is a viral infection that is self-limited and usually does not require
an inhaled medication. Bronchiectasis is a disease in which the respiratory tubules are permanently
enlarged. Symptoms include chronic production of purulent mucous.
A patient with pneumonia reports that he has rust-colored sputum. What pathogen should the nurse
practitioner suspect? (Streptococcus pneumonia)Clinical descriptions of mucus do not really help in clinical decision-making regarding pneumonia, but
certain clinical characteristics are associated with specific types of pneumonia. Strep pneumonia, also
known as pneumococcal pneumonia, is associated with rust-colored sputum. Scant or watery sputum is
associated with atypical pathogens like Mycoplasma and Chlamydophila pneumonia. Thick, discolored
sputum may be associated with bacterial pneumonia.
A 44-year-old nonsmoker is diagnosed with pneumonia. He is otherwise healthy and does not need
hospitalization at this time. Which antibiotic can be used for empirical treatment of pneumonia
according to the most recent Infectious Diseases Society of America/American Thoracic Society
guidelines? (Azithromycin)
The guidelines recommend macrolide use or doxycycline for initial treatment of uncomplicated
pneumonia in outpatients who are otherwise healthy and have not had recent antibiotic exposure. The
initial choices can be any of these: azithromycin, clarithromycin, or doxycycline. These agents are chosen
because they cover atypical pathogens, the most likely pathogen in this population. Fluoroquinolones
are commonly used first line in these patients; however, the guidelines strongly recommend using
fluoroquinolones for patients with comorbidities or patients who have recent antibiotic exposure.
The gold standard for diagnosing pneumonia on chest X-ray is the presence of: (Infiltrates)
The finding of infiltrates on chest X-ray, in conjunction with clinical findings of fever, chest pain, dyspnea,
and sputum production on clinical exam, should direct the examiner to consider pneumonia as the
diagnosis.
An 83-year-old healthy adult is diagnosed with pneumonia. He is febrile but in no distress. What is the
preferred treatment for him? (Levofloxacin)
At age extremes, the most common pathogen is Streptococcus pneumoniae. Because of the age of the
patient and the consequences of potential treatment failure, a respiratory quinolone should be
considered. Quinolone antibiotics can produce QT prolongation and should be used cautiously in older
adults. Azithromycin or doxycycline would be chosen if an atypical pathogen was suspected. This is
unlikely in this patient because of his age.
The pneumococcal immunization in infants has: (shifted the pathogenesis to fewer cases of S.
pneumonia)
The heptavalent pneumococcal conjugate vaccine (PCV13), Prevnar, protects children from 13 types of
pneumococcal bacteria. It has reduced the incidence of ear infections caused by S. pneumo and has
reduced the incidence of recurrent ear infections and tube placement by 10-20%. The pathogenesis of
acute otitis media has shifted to more cases of H. influenzae, but this organism is less likely to become
resistant, as Strep pneumo has.
A 78-year-old adult who has a 50 pack year smoking habit asks the nurse practitioner about the
benefits of quitting “at my age.” What should the nurse practitioner reply? (This will decrease your risk
of all cause mortality 5 years after stopping)
Smoking cessation at any age is beneficial to the person engaging in smoking cessation. Data
demonstrates that after 5 years of smoking cessation, there is a significant decrease in the risk of deathfrom coronary disease, cancer, and COPD. The patient already has COPD if he has a 50 pack year habit.
All patients should be counseled to quit smoking regardless of age.
M. pneumoniae and C. pneumoniae are respiratory pathogens that: (cause atypical pneumonia)
These two organisms are common causes of pneumonia. They are called atypical pathogens because
they produce atypical pneumonia. They are transmitted via respiratory droplets from the nose and
throat of infected people. Prolonged close contact is probably needed for transmission to occur. Patients
are usually contagious for 10 days or so. Most commonly, these infections occur in younger patients, but
all ages may be affected. Generally, the atypical pathogens are eradicated with macrolide antibiotics or
tetracyclines.
An 18-month-old child is diagnosed with bronchiolitis. His respiratory rate is 28 breaths per minute.
Which choice below is most appropriate for patient management? (Antipyretics)
Bronchiolitis is a viral infection and antibiotics would be inappropriate for management. Since fever
commonly accompanies bronchiolitis, antipyretics such as acetaminophen and ibuprofen are commonly
used. Bronchiolitis is characterized by wheezing. A normal respiratory rate for an 18-month-old is 20-30
breaths/minute. Bronchodilators, especially nebulized, and inhaled/oral steroids are commonly
employed to decrease respiratory effort. However, these interventions lack proven benefit, increase the
cost of care, and have many side effects.
How should a 20-year-old college age student who presents with cough, night sweats, and weight loss
be screened for TB? (A TB skin test)
Screening for TB in this patient should take place with a skin test known as the Mantoux. A chest X-ray is
typically performed after a positive skin test. A sputum specimen is used for diagnosis, not screening. A
questionnaire is used for screening patients who have had a history of a positive TB skin test. If
symptoms are acknowledged on the questionnaire, a chest X-ray may be performed. The questionnaire is
used to prevent inappropriate exposure to radiation in patients in whom regular screening is required,
like healthcare providers.
An example of a short-acting beta agonist is: (levalbuterol)
An example of a short-acting beta agonist is albuterol or levalbuterol. These provide rapid dilation of the
bronchioles and can give immediate relief for shortness of breath; hence the term for this class of
medications: rescue medications. Salmeterol is a long-acting beta agonist. These should never be used
without an inhaled steroid to treat a patient with asthma. Mometasone and beclomethasone are
steroids commonly used to treat patients with asthma.
A patient with asthma uses one puff twice daily of fluticasone and has an albuterol inhaler for PRN
use. He requests a refill on his albuterol inhaler. His last prescription was filled 5 weeks ago. What
action by the NP is appropriate? (Increase the dose of the inhaled steroid, refill the albuterol)
The patient is using his short-acting bronchodilator excessively if he needs a refill of his inhaler in only 5
weeks. Inhalers typically contain 200 puffs. They should be used two or fewer times per week. His
inhaled steroid dose should be increased and his albuterol inhaler should be refilled. In fact, he should
not be without a prescription for the albuterol. Consideration could be given to prescribing a long-actingbronchodilator and increasing the steroid, but this is not the best choice because this does not include a refill of the albuterol and this patient cannot be without access to a rescue inhaler.
Patients with asthma: (can cough or wheeze)
The second leading cause of cough in adults is asthma. Cough due to asthma is often accompanied by episodic wheezing or dyspnea, though some patients with asthma only cough. This is termed “cough variant asthma.” The clinical presentation of asthma varies but hyper-responsiveness of the airways is a typical finding.
A 26-year-old being treated for community-acquired pneumonia (CAP) has been taking azithromycin (standard dose) in therapeutic doses for 72 hours. His temperature has gone from 102° F to 101° F. What should be done? (Stop azithromycin and initiate a respiratory quinolone)
A 26-year-old with CAP should show improvement in symptoms in 24-48 hours if he is on appropriate antibiotic therapy. Azithromycin treats atypical pathogens like Mycoplasma and Chlamydophila, but, has poor Streptococcus coverage. The most likely pathogen in this age group that causes pneumonia is an atypical pathogen, but at this point the most common typical pathogen, Streptococcus pneumoniae, must be considered. The best choice is to consider Streptococcus pneumoniae as the pathogen and treat with a respiratory quinolone. Specifically, this patient should receive a respiratory quinolone because of the increased incidence of resistant Streptococcus pneumoniae (DRSP).
A 60-year-old patient newly diagnosed with COPD presents to your office. He would like to get the influenza immunization. He has no evidence of having had the pneumococcal immunization. What statement is correct? (He should receive both influenza and pneumococcal immunizations [Show Less]