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2024 - 2025 Walden NRNP 6540 Final
QUARANTEE PASS EXAM
**1. Mrs. Williams is 76 years old and comes in to have a wound checked on her right leg. She fell a month ago and the wound has not healed. She is concerned that something is wrong. The nurse practitioner examines the wound and sees that it has been cleaned properly and has no signs of infection. The edges are approximated, but the skin around the wound is red and tender to touch. The best response regarding Mrs. Williams' concern is:
- Wound healing for older people may take up to four times longer than it does for younger people.
- Let us talk about what you are eating.
- Had you come in earlier, I would have ordered medicine that would have healed that right up.
- I will order an antibiotic to prevent infection.**
- Answer: 1 Page: 96 Feedback
Skin renewal turnover time increases to approximately 87 days in older adults, compared with 20 days during youth.
The perceived extended healing time is not related to diet.
This is false hope, as there is no medication that will heal this wound quickly.
Prophylactic antibiotics are not appropriate when there are no signs or symptoms of infection. **2. The nurse practitioner is conducting patient rounds in a long-term care facility. As she talks with Mrs. Jones, she notices that her arms and elbows are excoriated and the skin is shearing. The nurse practitioner explains to the staff that Mrs. Jones needs frequent assessment of her skin and protection provided to prevent skin breakdown because:
- Her lack of activity causes the skin to tear.
- Fat has redistributed to the abdomen and thighs, leaving bony surfaces in areas such as the face, hands, and sacrum. This can result in injury.
- She has lost weight and is in jeopardy of falling.
- She picks at herself and causes skin breakdown.**
- Answer: 2 Page: 96 Feedback
Lack of activity alone does not cause skin breakdown.
Fat is redistributed to the abdomen and thighs, leaving bony surfaces, such as the face, hands, and sacrum, exposed to potential injury, especially skin tears from shearing, friction forces and pressure ulcer development.
Although losing weight may be a risk factor for falling, it is not directly related to skin breakdown.
There is no evidence that she is picking at herself, as there is nothing reported anywhere else on her arms. **3. Mr. James is 91 years old. His daughter notices that he has bruises and lacerations on his arms and reports this to the nurse practitioner, who tells her that older people bruise easily due to their fragile blood vessels. The skin lacerations happen because he has thin skin. Even so, the nurse practitioner assures the daughter that she will investigate further to ensure that he is getting proper care. She says this because she understands that:
- These markings on the patient's skin are part of aging skin.
- Bruises and lacerations can indicate inadequate care.
- The daughter needs assurance that her father is okay.
- The patient is being abused.**
- Answer: 2 Page: 97 Feedback
Markings on the skin may be signs of aging, a disease, or maltreatment.
Poorly healing wounds or chronic pressure ulcers may signal a problem not only with the patient but with the caregiver's ability to provide adequate care. Welts, lacerations, burns, and distinctive markings may indicate a need for intervention.
This is a result of the nurse practitioner addressing it further rather than the reason for addressing it.
A professional cannot assume abuse without good reason. 4. The nurse practitioner assesses a patient's skin and finds an infectious lesion on the lower leg. The lesion is considered a secondary lesion. The nurse
**2. Second degree
- First and second degree
- Second and third degree**
- Answer: 3 Page: 98 Feedback
First-degree burns involving the epidermis are erythematous and painful but do not blister.
Second-degree burns involve the dermis and are characterized by blisters.
The patient presents with erythematous skin, painful with blisters, which indicates both first- and second-degree burn areas.
In third-degree burns there is no sensation when the wound is pinpricked. **7. The nurse practitioner is concerned with primary prevention strategies. How can the nurse practitioner implement primary prevention strategies for an 80- year-old male patient who smokes?
- Review home fire safety protocols, including the proper use of smoke alarms, and discuss smoking cessation.
- Inform him that if he does not stop smoking, the nurse practitioner cannot see him again.
- Have a conference with his family about his smoking.
- Plan a family meeting with the patient to discuss benefits of his smoking cessation.**
- Answer: 1 Page: 115, 116 Feedback
Primary prevention includes educational programs designed to educate the public on safety. For example, the individual smoking in bed would hopefully benefit from smoking cessation programs in the community, as well as instruction in safety precautions.
Threatening refusal of care is not ethical.
The patient is at risk, not the family.
The fact that the patient smokes is not the issue; safety is the issue. 8. The nurse practitioner is conducting a safety class with community-living older adults. Which of the following should she include in her teaching of risks of burns for this population? Select all that apply.
**1. Thinner skin.
- Less vascularity.
- Diminished nerve function.
- A weakened immune system.
- The burden of various comorbidities leading to enhanced wound healing and reepithelialization after burn injury.**
- Answer: 1, 2, 3, 4 Page: 98 Feedback
As one ages, there are significant changes in the skin, which becomes thinner, providing a less effective barrier to external stimuli.
With aging, there are fewer appendages and decreased vascularity.
Thinner skin and diminished nerve function often result in a higher incidence of deeper burns.
Advanced age results in a weakened immune system.
Along with the burden of various comorbidities, the fragility of older skin leads to delayed wound healing and reepithelialization after burn injury. **9. Mr. Edwards is 76 years old and received a burn on his leg when he dozed off and dropped his cigarette. The nurse practitioner examines his leg for the degree of burn and classifies it as second degree with some third degree in the center. Mr. Edwards asks what that means and why it hurts so much. What is the best answer? Select all that apply.
- It means that this is a serious, deep burn in the center, and a less deep burn around the sides.
- It hurts because the nerve endings are exposed in the second-degree area.
- It means that the burn is advancing and getting worse.
- It hurts because the nerves are destroyed.
- It hurts because the nerves in the second-degree areas are exposed to the outside and are stimulated.**
- Answer: 1, 2 Page: 98 Feedback
Deep dermal burns extend further into the dermis; third-degree burns involve the full dermis, extending into the subcutaneous tissue.
**4. Necrotizing fasciitis
- Lymphangitis**
- Answer: 3 Page: 103 Feedback
Influenza is systemic and not localized in any one area.
The patient has no respiratory symptoms.
Signs of cellulitis include worsening of erythema, edema, tenderness, and pain that has occurred for a few days. Symptoms are usually sudden. Systemic symptoms which indicate serious toxicity include fever, hypotension, and tachycardia.
Necrotizing fasciitis exhibits diffuse swelling of an arm or leg with bullae.
Systemic symptoms that indicate serious toxicity include fever, hypotension, tachycardia, leucocytosis, lymphadenopathy, and lymphangitis. **12. The treatment for cellulitis includes which of the following? Select all that apply.
- Patients with mild cellulitis may be given oral antibiotics.
- One drug of choice is dicloxacillin, 500 mg four times a day.
- Treatment is dependent on the culture of the cells affected.
- The drug of choice is given for a minimum of 3 days.
- Administration of a tetanus booster injection.**
- Answer: 1, 2 Page: 103 Feedback
Oral antibiotics are sufficient for mild cellulitis and IV antibiotics for organisms such as MRSA.
There are several drugs effective with cellulitis; dicloxacillin is one of them.
Treatment of MRSA should be guided by wound culture results, but not cellulitis.
The drug of choice is typically given for 7 days.
If the wound is grossly contaminated and the patient's last tetanus booster was 5 to 10 years ago, the practitioner should consider giving another booster at this time.
**13. A 59-year-old female was admitted to the hospital for malaise, headache, fever, and flu-like symptoms. She has a decreased appetite and is having trouble sleeping. After a couple of days, she complains to the nurse practitioner of itching, burning, and tingling pain around her waist. The nurse practitioner advises the nursing staff to observe for vesicles for a few days. The patient asks why she is so sick. What would be the nurse practitioner's best response? Select all that apply.
- We are not certain at this point, however, these symptoms often occur before a break-out of herpes zoster.
- You have some very general systemic symptoms, so we are waiting for more specific symptoms to appear.
- Because you had chicken pox as a child, and you now have a depressed immune system, the chance of developing herpes zoster is high.
- These symptoms are probably a strong case of influenza.
- Herpes zoster is more com**
- Answer: 1, 3 Page: 106 Feedback
Patients usually experience itching, burning, or tingling pain at the site 4 to 5 days before the eruption appears.
Although there are general systemic symptoms, there is also itching, burning, and pain in the waist, which is leading to a herpes zoster diagnosis.
The patient has initial contact with VZV in the form of chicken pox. Individuals who are immunosuppressed are more likely to develop herpes zoster.
Herpes zoster is characterized by pain along the dermatomes and vesicles, which is not symptomatic of influenza.
This infection is most common in adults over 55 years old. The risk of herpes zoster increases with age. **14. Mrs. Person, 82 years old, comes to the well clinic to see a nurse practitioner for a bump on her ear. This growth has been there for almost a year but has recently grown. The area around the growth appears inflamed. Why would the nurse practitioner suggest a biopsy? Select all that apply.
- The growth is elevated and increasing in size.
- The ear has high exposure to the sun.
- There is inflammation around the growth.**
Avoiding occlusive footwear, wearing absorbent materials, and practicing good hygiene offer the best primary prevention.
Newer agents are more likely to cure tinea pedis than the older generation of antifungals, including clotrimazole, which is fungistatic, whereas terbinafine is fungicidal.
**1. In the assessment for peripheral vascular disorders, the clinician should begin with which of the following after the general history and physical examination?
- Auscultation of the carotid arteries bilaterally.
- Palpation of the carotid arteries bilaterally.
- Inspection of the carotid arteries bilaterally.
- Order diagnostic testing.**
- Answer: 1 Page: 215 Feedback
The clinician should begin with auscultation of the carotid arteries bilaterally because cardiac murmurs will usually radiate into the carotid arteries.
After auscultation of the carotid and subclavian arteries, the clinician should proceed to palpation of the brachial, radial, and ulnar arteries.
After auscultation and palpation, careful inspection should be performed of the distal fingers and the nail beds.
Diagnostic testing is usually ordered when areas of concern are found. **2. Which of the following conditions is signaled by symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid?
- Abdominal aortic aneurysm (AAA)
- Venous ulcers
- Peripheral vascular disease (PVD)
- Lymphedema**
- Answer: 4 Page: 218 Feedback
AAA presents the signal symptoms of persistent or intermittent pain in the middle or lower abdomen, radiating to the lower back.
Venous leg ulcers present signal symptoms of swelling that subside with elevation of lower extremities, eczematous skin changes, dull ache in lower extremities, and presence of varicosities.
PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. It presents signal symptoms of pain, intermittent claudication of the feet, and tissue loss in affected leg/arm.
Lymphedema presents the signal symptoms of swelling of the affected body part, usually the limb, because of impaired flow of lymph fluid.
**3. In the initial screening for a diagnosis of AAA, which of the following is the best screening test?
- CT scan
- Complete blood count (CBC)
- Ultrasound in the abdominal area
- Angiography**
- Answer: 3 Page: 216 Feedback
CT screening is indicated when surgery is planned.
CBC may be a secondary screening when surgery is planned.
Ultrasound in the abdominal area is the best initial screening test for AAA.
Angiography screening is indicated when surgery is planned. **4. Mrs. Prentiss is diagnosed with symptomatic AAA. The initial treatment is aggressive blood pressure control. At which of the following readings should mean arterial pressure be maintained?
- Between 100 and 120 mm Hg.
- Between 90 and 120 mm Hg.
- Between 60 and 70 mm Hg.
- Between 80 and 100 mm Hg.**
- Answer: 3 Page: 217 Feedback
A reading of 100 to 120 mm Hg is too high.
the best option for this scenario because of Anne's history.
Breast cancer is the best option and is a contributing factor for secondary lymphedema in Anne's case because of the previous mastectomy.
Urological cancer is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history.
Infection is a contributing factor for secondary lymphedema, but it is not the best option for this scenario because of Anne's history.
**7. PVD is a disease that alters blood flow to or from the extremities and vital organs other than the heart. According to studies, which of the following remains the most important risk factor for PVD?
- Smoking
- Hypertension
- Family history
- Hypercoagulopathy**
- Answer: 1 Page: 219 Feedback
Smoking remains the most important risk factor to PVD.
Hypertension is an associated risk factor to PVD.
A strong family history of the disease is an associated risk factor to PVD.
Hypercoagulopathy is an associated risk factor to PVD. **8. Which of the following differential diagnoses should be considered with the diagnosis of peripheral arterial disease (PAD)?
- Marfan syndrome
- Atelectasis
- Raynaud's phenomenon
- Carpal tunnel syndrome**
- Answer: 3 Page: 219, 220 Feedback
Marfan syndrome is a genetic disorder that affects the body's connective tissue. It is not
related to the diagnosis of PAD.
Atelectasis is a condition where some, or all, of the air-filled sacs (alveoli) inside the lungs collapse, thereby reducing the lungs' capacity to deliver oxygen to the body. It is not related to the diagnosis of PAD.
Raynaud's phenomenon is a type of vascular disease characterized by a pale to blue to red sequence of color changes of the digits, most commonly after exposure to cold, and should be considered with the diagnosis of PAD. Buerger's disease is also a differential diagnosis for this disease.
Carpal tunnel syndrome is a common condition that causes pain, numbness, and tingling in the hand and arm. It is not related to the diagnosis of PAD.
**9. Patient education is very important for individuals who have AAA. The patient and their family should be taught the importance of follow-up and the management of which of the following? Select all that apply.
- Hypertension
- Hypercholesterolemia
- Smoking
- Chondromalacia
- Pain**
- Answer: 1, 2, 3, 5 Page: 220, 221 Feedback
Education about hypertension management is important for patients with AAA. Antihypertensive agents are used to reduce tension on the vessel wall in patients with AAAs who have elevated blood pressure.
Patients with AAA need to learn about control of hypercholesterolemia (also called high cholesterol). Hypercholesterolemia is characterized by high serum cholesterol levels and premature coronary atherosclerosis. Hypercholesterolemia is one of the factors promoting the arteriosclerotic process and is a major cause of aortic aneurysm.
Smoking cessation should be considered by patients with AAA. Smoking appears to increase the risk of aortic aneurysms. Smoking can be damaging to the aorta and weaken the aorta's walls.
Chondromalacia is a pain in the knee and has no relationship to AAA.
Pain is the most common symptom of an AAA. Pain associated with an AAA may be in the abdomen, chest, lower back, or groin area. The pain may be severe or dull. Sudden, severe pain in the back or abdomen may mean the aneurysm is about to rupture.
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Nicardipine is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.
Sertraline is used to treat depression, panic attacks, obsessive compulsive disorder, post-traumatic stress disorder, and social anxiety disorder.
Esmolol is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.
Nitroglycerin is an IV antihypertensive agent that should be used to rapidly and consistently maintain blood pressure in mean arterial pressure ranges.
Carbidopa is a medication used with a combination to treat symptoms of Parkinson's disease or Parkinson-like symptoms.
**12. Lymphedema is characterized by swelling of the extremity. Which of the following symptoms are also presented with lymphedema? Select all that apply.
- Overall lethargy
- Aching in the affected area
- Restricted range of motion
- Purulence
- Cellulitis**
- Answer: 2, 3, 5 Page: 218 Feedback
Lethargy, or tiredness, is a state with a lack of energy and enthusiasm and not generally presented with lymphedema. Lethargy has been reported by people with multiple sclerosis, rheumatoid arthritis, hepatitis C, high blood pressure, and depression.
Lymphedema usually develops gradually over time and the swelling can be mild, moderate, or severe. Swelling, aching, discomfort, and fatigue in the affected limb may become present.
Restricted range of motion is a symptom presented with lymphedema due to the swelling in the affected limb.
Purulence is not presented with lymphedema.
Cellulitis is a sudden, noncontagious infection of the skin, characterized by redness, swelling, and heat, and is accompanied with pain and tenderness. Patients with
lymphedema are particularly susceptible to cellulitis because the lymphatic system is damaged or overloaded and does not function adequately to fight infection.
**13. Devon visits the urgent care facility for sudden symptoms of pain to his lower extremity. The initial diagnosis is acute arterial ischemia. Aside from pain, which other symptoms may arise from this diagnosis? Select all that apply.
- Pulselessness
- Paresthesia
- Pallor
- Purulence
- Paralysis**
- Answer: 1, 2, 3, 5 Page: 219 Feedback
Pulselessness is a symptom for acute arterial ischemia. Checking pulses is notoriously unreliable. Arterial Doppler signals should be checked in anyone with suspected acute limb ischemia.
Paresthesia is present in over 50% of cases. Sensory nerves are smaller than motor nerves and more sensitive to ischemia so tend to be affected first.
Pallor is especially useful in comparison to the opposite limb; it is also useful to check venous filling. Acutely ischemic limbs are classically white rather than blue. Chronic critically ischemic limbs may appear pink due to compensatory vasodilation, the so- called sunset foot.
Purulence is not a symptom that may arise from acute arterial ischemia diagnosis.
Paralysis is a poor prognostic sign and indicates an element of irreversible ischemia. **14. Treatment to slow the progression of PAD should include which of the following? Select all that apply.
- Immobilization
- Pharmacological
- Surgical
- Conservative
- Heat**
- Answer: 2, 3, 4 Page: 220 Feedback
the following?
**1. Asking about the sequence of events and events that triggered each episode.
- Conducting a complete neurological examination.
- Collecting a urine specimen.
- Evaluating abdominal pain.**
- Answer: 1 Page: 225 Feedback
Determining the sequence of events that triggered each symptom and inquiring about precipitating factors such as a meal, position of the body, use of caffeine, or alcohol and smoking will lead to a differential diagnosis.
Information regarding episodes of anorexia, dyspepsia, dysphagia, heartburn, nausea, regurgitation, vomiting, painful or difficult defecation, diarrhea, tenesmus, or constipation can be clustered to form a differential diagnosis.
The physical examination is often unremarkable, and laboratory findings may not provide diagnostic information because the presentation of illness in an older adult is usually subdued.
Ask about the severity of pain by having the patient rate her pain on a scale of 1 to 10. Realize, however, that in older adults, pain may be blunted despite the underlying pathology. **2. Part of the abdominal examination the nurse practitioner will conduct is the assessment of skin color. As the nurse practitioner assesses the abdominal skin, the findings include which of these signs that are concerning?
- Generalized pinkness.
- Bluish discoloration on the flanks.
- Yellow tint around the lower left quadrant.
- Blue in the upper left quadrant.**
- Answer: 2 Page: 226 Feedback
Pinkness is normal for a Caucasian patient.
If the bluish discoloration is on the flanks, this is known as Grey Turner's sign and is often indicative of retroperitoneal bleeding, as with pancreatitis.
Jaundice in the area of the umbilicus is known as Ransohoff's sign and is a result of a
ruptured common bile duct.
If a bluish discoloration is detected around the umbilicus, this is known as Cullen's sign, which is often found in patients with bleeding in the peritoneum.
**3. Mrs. M.W. asks the nurse practitioner what she is listening to in her belly and what it means. The nurse practitioner tells her that she is listening to determine:
- That her bowels are moving properly.
- If the blood vessels are not circulating blood.
- Circulation and bowel function.
- A diagnosis of her symptoms.**
- Answer: 3 Page: 226 Feedback
Studies have refuted the usefulness of auscultation when differentiating between patients with normal bowel sounds versus those with pathological bowel sounds.
Other sites to auscultate for bruits during an abdominal examination include the iliac arteries and the femoral arteries.
To auscultate for bruits during an abdominal examination, include the iliac arteries and the femoral arteries. When auscultating bowel sounds, take the time to listen for the presence of bowel sounds.
Nurse practitioners should not rely on auscultation alone for diagnostic purposes. **4. Mr. Person comes to the health-care clinic with a presenting symptom of not urinating as much as usual. The nurse practitioner assesses Mr. Person by asking which of the following?
- How much do you drink per day?
- Is your urine a clear yellow color?
- Do you experience urgency and frequency of urination?
- What medications have you taken recently or are you currently taking?**
- Answer: 4 Page: 228 Feedback
Patients may have nausea, vomiting, and diarrhea, leading to volume depletion.
The patient may have noticed a change in his urine consistency or color.
