NURS 6550 Final Exam Case Study Analyses

Posted: July 17th, 2022

NURS 6550 Final Exam Case Study Analyses

Case 1: Emergency Contraception for a 21-year-old Woman
A 21-year-old woman seeks emergency contraception after a condom break during intercourse, 16 hours ago, on day 14 of her 27–29 day cycle.

Analysis: Day 14 typically corresponds to ovulation in a 27-29 day cycle, making the woman more likely to conceive during this period. The nurse practitioner should advise her to take emergency contraception as soon as possible, with levonorgestrel (Plan B) or ulipristal acetate (Ella) being options. Levonorgestrel is effective up to 72 hours after unprotected sex, while ulipristal acetate can be taken up to 120 hours (5 days) and might be more effective in preventing ovulation at this point in her cycle.

Management: The patient should be informed of the time-sensitive nature of emergency contraception, with emphasis on immediate action. Additionally, a discussion on potential side effects, such as nausea or altered menstrual bleeding, is important. She should also be offered counseling on long-term contraceptive methods to avoid future emergencies.

Case 2: 38-year-old Woman with Chest Tightness and Migraine Medication
A 38-year-old woman presents with a rapid heartbeat, tremors, and chest tightness. She took a migraine pill given by a friend and is on a monoamine oxidase inhibitor (MAOI) for depression.

Analysis: The patient likely took sumatriptan or another triptan, which is contraindicated with MAOIs due to the risk of serotonin syndrome. Triptans, often used to treat migraines, work as serotonin receptor agonists, and combining them with MAOIs can lead to dangerously high serotonin levels.

Management: Immediate management includes assessing her for serotonin syndrome symptoms (e.g., hyperreflexia, agitation, sweating). The patient should be educated on the dangers of taking medications not prescribed for her, especially given her MAOI therapy. Future migraine treatments must be carefully selected to avoid interactions, with options like acetaminophen or NSAIDs being safer alternatives.

Case 3: 68-year-old Woman with a Urinary Tract Infection and Hearing Loss
A 68-year-old woman is treated for a UTI. She has a history of hypertension, diabetes, and dyslipidemia. She mentions difficulty understanding conversation in noisy environments.

Analysis: Her symptoms suggest presbycusis, a common form of age-related hearing loss, often affecting the ability to hear high-pitched sounds and comprehend speech in noisy environments. This condition can be exacerbated by her cardiovascular history (hypertension and diabetes), both of which are risk factors for hearing loss due to vascular changes affecting the inner ear.

Management: Referral to an audiologist for a hearing evaluation is warranted. Addressing her cardiovascular risk factors, such as optimizing diabetes and hypertension control, could help mitigate further hearing loss. In the meantime, hearing aids or assistive listening devices may improve her quality of life. Patient education on noise reduction techniques can also be beneficial.

Case 4: 73-year-old Woman with Foot Ulcer and Peripheral Arterial Disease
A 73-year-old woman with a history of COPD, PAD, and smoking presents with an ulcer on the sole of her left foot, described as having an irregular edge and pale base, and causing worse pain when the leg is elevated.

Analysis: This is likely an arterial ulcer, a common complication of peripheral arterial disease (PAD). The ulcer’s pale base, punched-out appearance, and worsening pain with leg elevation are typical of arterial ulcers, which occur due to poor blood supply to the affected area.

Management: Urgent referral to a vascular specialist is required to evaluate the extent of her PAD and assess the need for revascularization. Conservative management includes keeping the ulcer clean, controlling her blood sugar (if diabetic), optimizing her blood pressure, and ensuring she follows her COPD management plan. Smoking cessation is critical in preventing further vascular complications.
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NURS 6550 Final Exam

A 21-year-old woman requests hormonal emergency contraception after a condom break during intercourse approximately 16 hours ago. Today is day 14 of her normally 27–29 day menstrual cycle. You advise her that:
A quality improvement plan characterized by limiting variability and removing defects in a process best describes: +++> In this scenario, the nurse practitioner advises the patient that emergency hormonal contraception is most effective when taken as soon as possible after unprotected intercourse, ideally within 72 hours. However, it can still be effective up to 120 hours (5 days) after intercourse. The nurse practitioner should also discuss the various options for emergency contraception, such as levonorgestrel or ulipristal acetate, and their potential side effects.

Regarding the second question, a quality improvement plan characterized by limiting variability and removing defects in a process is best described as a “lean” process improvement strategy. This approach is based on the principles of reducing waste, increasing efficiency, and continuously improving quality by identifying and addressing root causes of problems. It involves standardizing processes, eliminating unnecessary steps, and focusing on value-added activities. The goal is to optimize the process to deliver high-quality outcomes with minimal variation and waste.

A 38-year-old woman comes to the emergency department complaining of a rapid heartbeat, tremors, and chest tightness. She reports earlier in the day she was feeling a migraine starting so she took a pill given to her by her friend who also experiences migraines. Her medical history reveals that she is currently taking a monoamine oxidase inhibitor for depression. Which migraine medication did she most likely take?
You are seeing a 68-year-old woman for treatment of an uncomplicated urinary tract infection (UTI). She has well-controlled hypertension, type 2 diabetes mellitus, and dyslipidemia and takes an angiotensin-converting enzyme inhibitor (ACEI), statin, biguanide, and low-dose aspirin (ASA). She worked in a dry cleaning facility until approximately 8 years ago. During her Assessment, she mentions that she sometimes has difficulty understanding conversation, especially in noisy environments. This is likely a:
While evaluating a 33-year-old female with a 2-day history of dysuria, which of the following findings in urinalysis is most suggestive of urinary tract infection (UTI) caused by a Gram-negative organism?
Nitrites
All of the following are examples of primary prevention strategies except:
A 23-year-old woman is being evaluated for an upper respiratory tract infection. As you prepare for auscultation, the patient states “I have a benign murmur that has been with me my whole life”. Anticipating a physiologic murmur, you would expect which of the following characteristics?
Usually obliterates S2.
When evaluating the value of a test, the proportion of negative results that are truly negative best describes:
A 16-year-old male presents for Assessment after a syncopal episode at school. He reports that he has recently been experiencing bouts of lightheadedness. His blood pressure is 126/76 mm Hg and his BMI=33 kg/m 2 . You notice velvet-like plaques at the nape of the neck. Laboratory assessment should include which of the following tests?
A 48-year-old woman is being evaluated with chief complaints of fatigue, weakness, lethargy, and decreased concentration. She also mentions a notable increase in facial hair over the past 6 months as well as unexplained weight gain (about 25 lbs [11.3 kg]) over the past 2 months. Her past medical history is notable for moderate persistent asthma with multiple exacerbations over the past 8 months requiring treatment with prednisone. The most likely diagnosis is:
You see a 73-year-old woman with a 40 pack-year smoking history, chronic obstructive pulmonary disease (COPD) and peripheral arterial disease (PAD) who presents with an ulcer on the sole of her left foot. The ulcer has an irregular edge and pale base and a punched out appearance, with the surrounding skin white and shiny. The patient states that the pain is worse at night in bed and when the legs are elevated. The most likely diagnosis is:
In evaluating a 62-year-old male with ischemic heart disease and mitral incompetency, you expect to find the murmur that is:
You see a 76-year-old woman living at home who is accompanied by her home care provider. She has COPD and type 2 diabetes mellitus. An example of a secondary prevention strategy is:
A 43-year-old woman is being evaluated in the emergency department with a complaint of a severe headache. She describes a unilateral, pulsing headache that was preceded by a gradual onset of paresthesia affecting the ipsilateral face and arm. The patient stated she noticed a “funny smell” prior to the symptoms starting. This description is most typical of:
You see a 54-year-old man living in subsidized housing with a history of hypertension. He states that he stopped taking his blood pressure medication about 4 months ago because of costs. He is concerned because his blood pressure is high whenever he checks it, though he does not report any symptoms. His BP at this visit is 196/104 mm Hg. Upon examination of this patient, you would expect to detect an S 4 sound heard during:
32-year-old man requires Assessment for hepatitis infection prior to taking a job as a restaurant cook. He presents with the following laboratory results:
When evaluating illness symptoms in older patients, the disease will often present differently from younger adults due to:
When prioritizing risk factors for bacterial endocarditis, the nurse practitioner knows who among the following patients has the highest risk.
The legal authority for NPs to perform healthcare services as defined by state law is called:
A patient who was seen for an upper respiratory tract infection has an abnormal blood test result and requires a follow-up visit. The patient repeatedly fails to show up for the follow-up visit. Which of the following is the best approach to inform the patient of the need and urgency for a repeat test?
When developing a management plan for patients with genitourinary infections, which of the following would you most likely recommend for follow-up imaging following resolution of their infection?
The NP is called to evaluate Jane, a 43-year-old woman, who presents with a diffuse maculopapular rash that began on the trunk but now covers the entire body, including the palms and soles. The rash is not itchy but wart- like sores are present in the mouth and genital area as well as skin folds. Initial Assessment reveals generalized lymphadenopathy and a low-grade fever, and she complains of lethargy and headache. The patient reports that she had a painless genital ulcer that healed on its own about 3 weeks earlier. Which of the following is the most likely diagnosis?
A 27-year-old man presents with a chief concern of an abnormal mass within his left scrotum. He describes it as feeling like a “bag of worms” and is present when he is standing but disappears when he lies down. His past medical history is unremarkable and his BMI is 29 kg/m 2 . He has been in a monogamous relationship for the past 4months. The most likely diagnosis is:
A 67-year-old man is being evaluated for shortness of breath. His medical history reveals that he experienced a myocardial infarction about 2 years ago and a history of hypertension, which is well controlled by diet..
Otherwise, his medical history is unremarkable. Which of the following would you expect to find on electrocardiogram (ECG)?

A 74-year-old male with asymptomatic atrial fibrillation underwent electrical cardioversion that successfully restored the heart’s rhythm. Which of the following medications can be considered for the purpose of maintaining the heart’s rhythm? +++> After successful electrical cardioversion, the patient may be considered for maintenance of sinus rhythm with antiarrhythmic medication. The choice of medication will depend on various factors, including the patient’s medical history, concomitant medications, and presence of structural heart disease. Some commonly used antiarrhythmic medications for maintaining sinus rhythm in patients with atrial fibrillation include:

Amiodarone
Dofetilide
Flecainide
Propafenone
Sotalol
The decision to initiate antiarrhythmic medication should be made in consultation with a cardiologist or other experienced healthcare provider. It is important to weigh the potential benefits against the risks of adverse effects and drug interactions. Close monitoring of the patient’s cardiac rhythm and drug levels may also be necessary to ensure safety and efficacy.

A 14-year-old male is brought in for Assessment after he reportedly collapsed during a tennis match, though he quickly regained consciousness. His medical history is otherwise unremarkable. You suspect hypertrophic cardiomyopathy. Which of the following heart murmur characteristics would support the diagnosis?
You see a 64-year-old man with an area of erythema concentrated on the left side of his neck with clusters of vesicles forming a line. He reported pain in the area a couple of days before the eruption of the lesions. He states that he recently initiated biologic therapy for rheumatoid arthritis. Which of the following is the most likely diagnosis?
An NP’s duty of care can be established:
A 49-year-old woman presents with a 3-day history of burning during urination, a thin and grayish-white vaginal discharge, and vagina itching. On laboratory examination, you expect to find all of the following except:
The NP is called to evaluate a 34-year-old nonpregnant woman who complains of a 4-week history of anxiety, palpitations, diarrhea, unexplained weight loss, and sensitivity to heat. Her medical history is unremarkable and she is not taking any medications. Physical examination reveals warm, moist skin and exaggerated deep tendon reflexes. The NP suspects Graves’ disease. Which of the following laboratory results would best support this diagnosis?
In managing a 58-year-old woman who is admitted for deep vein thrombosis, caution should be used with which of the following medications due to a risk of drug-induced thrombocytopenia?
A 27-year-old woman with a known sulfa allergy presents with an uncomplicated UTI. She has not received any systemic antimicrobials in the past 6 months. She is currently not pregnant and is using norelgestromin/ethinyl estradiol patch (Ortho Evra ® ) for birth control. You recommend treatment with:
You are examining a 64-year-old woman with a history of rheumatic heart disease. In assessing the patient for mitral stenosis, you expect to find a heart murmur characterized as:
21-year-old female student presents at the university clinic with a nosebleed. This is her third bleeding episode in the past week. She is otherwise healthy with no history of bleeding disorders. The NP advises that the appropriate first-line intervention for anterior epistaxis is:
Which of the following examples describes a potential malpractice scenario?
An 84-year-old female patient is admitted from a local long-term care facility (illnes). The patient is normally awake, alert, and oriented. She resides in the LTCF because she has not fully recovered from a broken hip resulting from a fall 4 months ago; otherwise she is in relatively good health. She can walk short distances with a walker, though she primarily stays in a wheelchair. Today, however, the nursing staff found her to be acutely confused and unable to ambulate without falling. She was transferred to the emergency department for Assessment. Initial laboratory testing must include:
The NP is called to evaluate a 56-year-old man complaining of severe pain in the upper right abdomen that radiates to the right shoulder, nausea and vomiting, which started soon after dinner. The NP suspects acute cholecystitis. All of the following findings would be consistent with the diagnosis except:
A 23-year-old college student presents with a 2-day history of severe sore throat and difficulty eating or drinking due to trouble swallowing. A physical examination reveals exudative pharyngitis and minimally tender anterior and posterior cervical lymphadenopathy. The NP suspects infectious mononucleosis and would expect which of the following laboratory findings?
A 45-year-old male is being prepared for release after receiving analgesic treatment for low back pain due to an acute lumbosacral strain. He is in otherwise good health and typically exercises on a daily basis. He asks when he will be able to start exercising again. The most appropriate response is:
“Incident-to” services are defined as those which are “an integral, although incidental, part of the physician’s personal professional services in the course of diagnosis or treatment of an injury or illness”. As long as certain criteria are met, “incident to” billing is an option in all of the following settings except:
A 78-year-old male is being treated for a hypoglycemic episode. He has a long history of type 2 diabetes mellitus as well as congestive heart failure and COPD. He is currently taking basal insulin with a sulfonylurea. What is the acceptable A1C goal for this patient?
A 47-year-old woman reports that her long-time boyfriend was recently diagnosed with liver cancer possibly caused by a chronic hepatitis B infection. Though she does not have any symptoms, she wants to be checked for hepatitis B. She can’t recall if she has ever been vaccinated for hepatitis B. The laboratory results are as follows:
You see a 74-year-old male who is accompanied by his granddaughter who lives with him. He has hypertension, a prior myocardial infarction, long-standing type 2 diabetes, and recently underwent a lower limb amputation secondary to diabetes. He is currently taking an ACE inhibitor, statin, low-dose aspirin, biguanide, and insulin. The granddaughter reports that since the amputation, her grandfather sometimes becomes withdrawn, irritable and moody for no apparent reason, does not want to participate in the typical activities he enjoys, and often does not appear to eat much during the day. She also states that he often complains of being tired but normally wakes up in the early morning hours. The most appropriate action is to evaluate the patient for:
A 15-year-old male is brought in to the emergency department by his parents following a 12-hour history of nausea, vomiting, and abdominal pain. Physical examination reveals obturator and psoas signs and a temperature of 102.6ºF (39.2ºC). Anticipated white blood cell (WBC) with differential results are as follows:
You see a 58-year-old man who complains of a persistent dry, hacking cough. He reports that he recently started taking a medication to treat high blood pressure. He is most likely taking a(n):
A 77-year-old woman is accompanied by her husband for Assessment. She is currently being treated with metoprolol (Lopressor ® ) for hypertension and digoxin (Lanoxin ® ) for atrial fibrillation. He reports that his wife is becoming increasingly forgetful over the past year, failing to note important family events such as birthdays, and sometimes becomes confused with driving directions to familiar locations. She has no previous psychiatric history. The most likely diagnosis is:
The NP is called to evaluate a 51-year-old man with acute bacterial rhinosinusitis. He currently smokes 1 PPD and has a 30 pack-year cigarette smoking history. His medical history shows that he is allergic to penicillin.
Mrs. Conner is a 76-year-old woman living in a long-term care facility and has been bedridden with a respiratory infection for the past 4 days. She is brought in for Assessment and you note signs of dehydration as well as a section of epidermal skin loss about 3 cm in diameter on her right hip. The dermal layer appears intact. This would be considered a pressure ulcer of Stage:
Which of the following represents the highest level of scientific evidence when evaluating clinical research?
A 64-year-old woman with chronic kidney disease presents with a chief complaint of lethargy. His hemogram is as follows:
The NP is called to evaluate a 57-year-old man who reports episodes of acute angina with physical exertion. He is currently taking an ACE inhibitor and low-dose aspirin. The NP considers which of the following approaches at the start of anginal symptoms?
You see a 68-year-old woman who is being treated for moderate depression. She complains that her medication is causing symptoms of dry mouth and constipation. She is most likely taking which of the following medications?
All of the following persons are eligible for Medicare services except:
A 35-year-old woman presents with a chief complaint of being unable to close her right eyelid tightly, frown, or smile on the right side. She is otherwise healthy with no significant prior medical history. An appropriate diagnostic test for this patient would be:
When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, you advise the patient to return in 5 days to check which of the following laboratory parameters? ++++> The patient’s symptoms suggest a possible facial nerve palsy, which could be due to a variety of causes including viral infection, trauma, or tumor. An appropriate diagnostic test for this patient would be a thorough neurological exam, including assessment of cranial nerves and Assessment for signs of any other neurological deficits. In addition, imaging studies such as MRI or CT may be ordered to evaluate for any underlying structural abnormalities or masses.

When initiating therapy with spironolactone for a patient who is also on an ACE inhibitor, it is important to monitor serum potassium levels. Both drugs can increase serum potassium levels, and concomitant use can increase the risk of hyperkalemia. Therefore, it is advisable to check serum potassium levels 5 days after initiating therapy to ensure that the patient is not experiencing hyperkalemia.

A 27-year-old male is rushed to the emergency department after experiencing a series of seizures. He has no history of neurologic disorder. His girlfriend states that he was taking multiple medications for mood disorder but recently stopped taking one of them. The most likely medication the patient discontinued is a:
When considering an end-of-life decision for a terminally ill person with Alzheimer-type dementia who can no longer communicate, all of the following can be used as an advanced directive except:
Which of the following types of clinical studies represents the lowest level of evidence used to guide medical decisions?
Which of the following electrocardiogram (ECG) changes do you expect to find in a person with myocardial ischemia?
A 17-year-old male with intermittent asthma presents for routine follow-up. He explains that he experiences asthma symptoms once or twice each week, usually during physical activity. Symptoms are promptly relieved each time with albuterol per MDI with spacer. He does not report any nighttime awakenings due to his asthma. His ACT score is 24 and vital signs are all within normal limits. According to the NAEPP EPR-3, what is the next step in the management of his asthma?
A 41-year-old woman is diagnosed with hypertension that requires medication. She is otherwise healthy but currently taking drospirenone/ethinyl estradiol (Yasmin ® ) for birth control. Which of the following antihypertensive medications would be least preferred for this patient?
Which of the following statements is false regarding end-of-life decision-making for a patient that is hopelessly and terminally ill?
The nurse practitioner is evaluating a 19-year-old male suffering from a severe headache. He has a history of headaches that tend to occur in clusters over a few days. He has unsuccessfully tried several therapeutic modalities. A positive response to which of the following interventions supports the diagnosis of cluster headache?
A 68-year-old woman who resides in a long-term care facility is being treated for a urinary tract infection. Her medical history includes hypertension, peripheral artery disease, and a 35 pack-year smoking history. During the Assessment, she brings to your attention a painless, pearly nodule on the upper lip. This clinical presentation most likely represents a(n):
All of the following are required Medicare terms and conditions for paying NP services except: The services are within the NP’s scope of practice as defined by state law.
The services performed are those for which a physician would be able to bill Medicare. The services are performed in collaboration with a physician.

A 17-year-old male is admitted after experiencing sudden, severe pain in the scrotum during the night. Physical examination reveals swelling of the scrotum and the loss of the cremasteric reflex. His heart rate is 110 bpm, blood pressure 150/80 mm Hg, and temperature 99.8ºF (37.7ºC). This most likely represents:
Testicular neoplasia
According to the Consolidated Omnibus Reconciliation Act (COBRA), the spouse of an eligible employee will be eligible for COBRA coverage in all of the following circumstances except when the eligible employee:
A 28-year-old male with asthma presents with a chief complaint that he has to use his rescue inhaler multiple times each day. An Assessment reveals that he has moderate-to-severe asthma and requires Step 4 treatment. An appropriate regimen would include:
A 62-year-old woman presents in the emergency department complaining of severe toe pain that originated overnight. She has a history of renal disease and is currently taking a thiazide diuretic. Her BMI is 37 kg/m 2 . In considering a diagnosis of acute gouty arthritis, the nurse practitioner knows that the best diagnostic indicator is:
While taking the history on a 61-year-old female patient, the nurse practitioner learns that she has a 15-year history of poorly-controlled hypertension. The patient admits that another provider had told her that the high blood pressure had affected her eyes. As a result, the nurse practitioner expects that funduscopic examination will likely reveal: +++> The best diagnostic indicator for acute gouty arthritis is the presence of monosodium urate crystals in synovial fluid aspirated from an affected joint. These crystals are typically needle-shaped and negatively birefringent under polarized light.

Regarding the second question, long-standing hypertension can cause damage to the blood vessels in the eyes, resulting in a condition known as hypertensive retinopathy. This can manifest in various ways on funduscopic examination, including arteriolar narrowing, arteriovenous nicking, cotton wool spots, and hemorrhages. The specific findings observed will depend on the severity and duration of the hypertension.

A 28-year-old woman presents who complains of tugging chest pain unrelated to physical activity. She is generally in good health, a non-smoker, has a BMI of 23 kg/m², and denies dyspnea or dizziness. Physical examination reveals a grade 2/6 late systolic murmur that follows a midsystolic click at the 5th intercostal space, mid-clavicular line. An echocardiogram fails to reveal mitral valve tissue redundancy. This clinical presentation is most consistent with:
A physician employs an NP to provide services at a satellite acute care clinic. If the physician is never present at the clinic, which of the following statements is true?
Which of the following describes the ethical principle of beneficence? +++> The clinical presentation described is most consistent with mitral valve prolapse (MVP), a condition in which the valve leaflets bulge back into the left atrium during systole. The mid-systolic click and late systolic murmur are characteristic of MVP. However, it is worth noting that not all patients with MVP have redundant mitral valve tissue on echocardiogram, and some individuals with redundant tissue do not have symptoms.

Regarding the second question, if the physician is never present at the clinic, it is important to note that the NP is still required to work within the scope of their practice and follow all applicable laws and regulations. The NP should also have access to appropriate resources and support, such as a physician available for consultation if needed.

Finally, the ethical principle of beneficence refers to the obligation to do good and act in the best interest of the patient. This can involve actions such as providing effective treatment, avoiding harm, and respecting patient autonomy.