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NR 602 Final Exam Week 4 : Dermatology
1.What is the Ortolani Sign? (Assess for congenital hip dysplasia) 2.When performing a physical examination of a toddler, which of the following body parts would you examine last? (Throat and Ears) 3 .Concurrent Otitis media and conjunctivitis is likely due to which? (Haemophilus Influenza) 4.What are the three findings using Jones criteria for Rheumatic fever? (streptococcal infection, carditis and erythema marginatum) 5.If a child or a patient describes a “pop” in the knee. What does this indicate? (Anterior cruciate ligament tear) 6.The most appropriate management of a child with asthma who presents with acute wheezing or coughing would be? (Administer a short-acting beta agonist) 7.In addition to penicillin, which antibiotic can’t be used to treat strep pharyngitis? (Bactrim) 8 .A microscopic examination of the sample taken from a skin lesion indicates hyphae. What type of infection might this indicate? (Fungal) 9 .A child with a sandpaper-textured rash probably has: (Strep infection) 10 .A 40-year-old female patient presents to the clinic with multiple, painful reddened nodules on the anterior surface of both legs. She is concerned. These are probably associated with her history of: (ulcerative colitis)
- A patient is diagnosed with tinea pedis. A microscopic examination of the sample taken from the infected area would likely demonstrate: (hyphae) 12 .When can a child with chickenpox return to daycare? (After all lesions have crusted)
13 .A patient with a primary case of scabies was probably infected: (3-4 weeks ago) 14 .The nurse practitioner examines a patient who has had poison ivy for 3 days. She asks if she can spread it to her family members. The nurse practitioner replies: (“No, transmission does not occur from the blister’s contents”) 15 .Which chronic skin disorder primarily affects hairy areas of the body? (Seborrheic dermatitis) 16 .A patient with diabetes has right anterior shin edema, erythema, warmth, and tenderness to touch. This developed over the past 3 days. There is no visible pus. What is the most likely diagnosis to consider? (Cellulitis) 17 .The agent commonly used to treat patients with scabies is permethrin. How often should it be applied to eradicate scabies? (Once) 18 .Impetigo is characterized by: (honey-colored crusts) 19 .A 60-year-old patient is noted to have rounding of the distal phalanx of the fingers. What might have caused this? (Hepatic cirrhosis)
- A patient has suspected scarlet fever. He likely has a sandpaper rash and: (a positive rapid Strep test) 21 .A patient with a positive history of a tick bite about 2 weeks ago and erythema migrains has a positive ELISA for Borrelia burgdorferi. The Western blot is positive. How should he be managed? (He should receive doxycycline for Lyme disease)
- A patient will be taking oral terbinafine for fingernail fungus. The NP knows that: (terbinafine is an inhibitor of the CYP 2D6 enzymes)
- A skin lesion that is a solid mass is described as a: (papule) A papule is an elevated solid mass up to 1.0 cm. in diameter. 24 .The nurse practitioner is examining a 3-month-old infant who has normal development. She has identified an alopecic area at the occiput. What should be done? (Encourage the caregiver to change the infant’s head position)
37 .A patient has seborrheic dermatitis. Which vehicle would be most appropriate to use in the hairline area to treat this? (Foam) 38 .A patient with eczema asks for a recommendation for a skin preparation to help with xerosis. What should the NP respond? (Use a petroleum-based product) 39 .A topical treatment for basal cell carcinoma is: (5-fluorouracil) 40 .The most common place for basal cell carcinoma to be found is the: (Face) 41 .An infant is diagnosed with diaper dermatitis. Satellite lesions are visible. This should be treated with a: (topical antifungal agent) 42 .A 3-year-old female had a fever of 102° F for the last 3 days. Today she woke up from a nap and is afebrile. She has a maculopapular rash. Which statement is true? (The rash will blanch) 43 .A 71-year-old female presents with a vesicular rash that burns and itches. Shingles is diagnosed. An oral antiviral: (should be started within 72 hours of the onset of symptoms) 44 .A skin disorder has a hallmark finding of silvery scales. What word below describes this common condition? (Chronic) 45 .A child has 8-10 medium brown café au lait spots > 1 cm in diameter. The differential diagnosis should include: (neurofibromatosis) 46 .A low-potency topical hydrocortisone cream would be most appropriate in a patient who has been diagnosed with: (atopic dermatitis) 47 .A patient is found to have koilonychia. What laboratory test would be prudent to perform? (Complete blood count) 48 .A 23-year-old male appears in clinic with the following lesion on his trunk. This lesion is usually associated with: (pityriasis rosea)
49 .A 28-year-old has thick, demarcated plaques on her elbows. Which features are suggestive of psoriasis? (Silvery scales that are not pruritic) 50 .Which of the following skin lesions in an older adult is a premalignant condition? (Actinic keratosis) 51 .A patient presents with plaques on the extensor surface of the elbows, knees, and back. The plaques are erythematous and thick, silvery scales are present. This is likely: (plaque psoriasis) 52 .A 15-year-old male has worked this summer as a lifeguard at a local swimming pool. He complains of itching in the groin area. He is diagnosed with tinea cruris. The nurse practitioner is likely to identify: (well marginated half-moon macules on the inner thigh) 53 .A 68-year-old female adult with pendulous breasts complains of “burning” under her right breast. The nurse practitioner observes a malodorous discharge with mild maceration under both breasts. What is this? (Intertrigo) 54 .An example of a first-generation cephalosporin used to treat a skin infection is: (cephalexin) 55 .A patient has a “herald patch” and is diagnosed with pityriasis rosea. Where is the “herald patch” most commonly found? (On the chest) 56 .A 16-year-old has been diagnosed with Lyme disease. Which drug should be used to treat him? (Doxycycline) 57 .A 9-year-old female has presented to your clinic because of a rash on the left, upper area of her anterior trunk. She is embarrassed and very reticent to lift her blouse because her nipple will be exposed. How should the NP proceed? (Examine all other areas of the trunk, then ask the child to lift her blouse) 58 .Hand-foot-and-mouth disease and herpangina: (are viral infections caused by Coxsackie viruses) 59 .A 74-year-old male patient has sustained a laceration to his foot. His last tetanus shot was more than 10 years ago. He has completed the primary series. What should be recommended? (Tetanus, diphtheria, and acellular pertussis (Tdap))
The primary cause of pruritus associated with hives is histamine release. Histamine is released from mast cells with other substances of anaphylaxis. Antihistamines are the primary therapeutic intervention. Topical steroid use is not helpful. Calcium channel blockers (nifedipine) are used as a “last resort” for refractory cases of urticaria. Steroids do not inhibit mast cell degradation and so are less helpful than thought. Steroids can be used for persistent attacks of acute urticaria if antihistamines are not helpful. 69 .The lesions seen in a patient with folliculitis might be filled with: (pus) Folliculitis is a superficial inflammation of hair follicles usually caused by bacteria. As a superficial infection, it involves only the epidermis. When this occurs, there are usually numerous pustular lesions. The composition of pus is dead white cells and other cellular debris. 70 .Which vehicle is least appropriate in a patient who has atopic dermatitis? (Lotions) Patients who have atopic dermatitis need continuous skin hydration. Lotions can worsen xerosis (dry skin) due to evaporation of water on the skin. In contrast to creams and ointments, lotions have a high-water content and a low oil content. Creams have a lower water content. Ointments have no water and are excellent agents to use on dry skin as well as to prevent dry skin. 71 .A patient has been diagnosed with scabies. What is the medication of choice to treat this? (Permethrin) Scabies is eradicated by using permethrin and good hygiene. All household and personal contacts must be treated simultaneously, and meticulous care must be exercised to prevent transmission by cross contamination. All clothing, stuffed animals, linens, mattresses, and cloth furniture must be treated to prevent further transmission. 72 .The American Cancer Society uses an ABCDE mnemonic to help patients develop awareness of suspicious skin lesions. What does the “B” represent? (Border) The mnemonic is helpful when looking at skin lesions, but it is primarily used for patient education. The “A” represents asymmetry (asymmetrical lesions are worrisome), “B” is border (irregular borders), “C” is color (colored lesions have more melanin and may be associated with malignant melanoma), “D” is diameter (larger than a pencil eraser [6 mm] is concerning), and “E” represents enlarging or elevated (lesions that are actively enlarging are growing; elevated lesions are concerning). 73 .A “herald patch” is a hallmark finding in which condition? (Pityriasis rosea)
Pityriasis rosea (PR) is a self-limiting exanthemata’s skin disorder characterized by several unique findings. It is more common in young adults. A characteristic finding is the “herald” or “mother” patch found on trunk. This looks like a ringworm and precedes the generalized “Christmas tree” pattern rash. The lesions associated with the rash are salmon-colored and oval in shape. Most cases clear in 4-6 weeks, but the plaques may last for several months. 74 .A patient has used a high-potency topical steroid cream for years to treat psoriasis exacerbations when they occur. She presents today and states that this cream “just doesn’t work anymore.” What word describes this? (Tachyphylaxis) Tachyphylaxis is the word used to describe a gradual and progressively poorer clinical response to a treatment or medication. This is particularly true of topical glucocorticoids, bronchodilators, nitroglycerine, and antihistamines when they are overused. The rebound effect describes a condition in which initial clinical improvement occurred, but worsening has occurred. Lichenification refers to a thickening of the skin. Drug-free intervals are important to prevent tachyphylaxis. 75 .A patient has been diagnosed with MRSA. She is allergic to sulfa. Which medication could be used to treat her? (Doxycycline) MRSA is methicillin-resistant Staph aureus. This is very common in the community and is typically treated with sulfa medications like TMP/SMX (Bactrim DS and Septra DS). If the patient is allergic to sulfa, this should not be used. A narrow- spectrum antibiotic that can be used is doxycycline or minocycline. It is given twice daily and is generally well tolerated. MRSA is resistant to the antibiotics in the other choices and so they should NOT be used to treat it. 76 .Topical 5-fluorouracil (5-FU) is used to treat: (basal cell carcinoma) 5 - FU is a topical agent that can be used to treat basal cell carcinoma (BCC). It is most effective on rapidly proliferating cells. This treatment should only be used on superficial BCCs. If it is used on more invasive BCC, the cure rate is significantly lower. Therefore, 5-FU should be used only on superficial BCCs in noncritical locations. It is dosed as a 5% formulation twice daily for 3-6 weeks. 77 .A patient was burned with hot water. He has several 2-3 cm fluid-filled lesions. What are these termed? (Bullae) Bullae are fluid-filled lesions that are greater than 6 mm in diameter. These are common in patients who have a superficial partial-thickness burn. Vesicles are also fluid filled, but they are smaller than 5 mm in diameter. A cyst is enclosed in a sac that can contain fluid or gelatinous material. Wheals are erythematous, irregular raised areas on the skin. All of these are termed primary lesions. 78 .A child received a burn on his chest from a cup of hot coffee. On examination, the injured area appeared moist, red to ivory white in color,
usually is a result of liver disease, but it can be due to excessive hemolysis of red blood cells. In infants, the usual cause is hemolysis of red blood cells, as is seen in physiologic jaundice. 81 .The term caput succedaneum refers to: (scalp edema) Caput succedaneum is a common finding in newborns. It is a result of pressure over the presenting part. This results in some ecchymosis of the scalp. While this may be disturbing to new parents who observe this in their newborn, it will resolve in a few days and is harmless. 82 .A 4-year-old has been diagnosed with measles. The nurse practitioner identifies Koplik’s spots. These are: (found on the inside of the cheek and are granular) Koplik’s spots are found in the oral cavity, especially on the buccal mucosa opposite the first and second molars. The spots are white and granular and are circled by an erythematous ring. The spots are pathognomonic for measles. The exanthem associated with measles is typically described as cranial to caudal in progression. The lesions become confluent and last for approximately 4 days before fading begins. 83 .A patient calls your office. He states that he just came in from the woods and discovered a tick on his upper arm. He states that he has removed the tick and the area is slightly red. What should he be advised? (No treatment is needed) Many factors must be present for a patient to develop Lyme disease from a tick bite. First, the tick must belong to Ixodes species. The tick must have been attached for at least 48 hours before disease can be spread. Time of year and stage of organism development affect transmission. There is no need for prophylactic treatment in this case because the tick has not been present long enough, though many patients will feel antibiotics are necessary. He could be checked to ensure that the entire tick has been removed. 84 .A wound has the following characteristics; partial thickness loss of dermis, a shallow open ulcer with red/pink bed, and no evidence of sloughing. What stage of pressure ulcer does this describe? (Stage II) Stage I is characterized by intact skin and nonblanchable redness of a localized area (usually over a bony prominence). Compared to adjacent tissue, the area may be painful, firm, soft, warmer or cooler. Stage II is characterized by partial-thickness loss of dermis presenting as a shallow open ulcer or a red-pink wound bed, absent sloughing. It may also present as an intact or open/ruptured serum-filled blister. Stage III is characterized by full-thickness tissue loss with or without visible subcutaneous fat; bone, tendon, and muscle are not exposed. Sloughing may be present but does not obscure the depth of tissue loss. The depth varies by anatomical location. Stage IV is characterized by full-thickness tissue loss with
exposed bone, tendon, or muscle. Sloughing or eschar may be present on some parts of the wound bed. The depth varies by anatomical location. 85 .A patient has been in the sun for the past few weeks and has developed darkened skin and numerous 3-6 mm light-colored, flat lesions on his trunk. What is the likely etiology? (Tinea versicolor) Tinea versicolor is typically visualized during the spring and summer months when a patient has become darkened after sun exposure. The areas that are infected do not tan and so become very noticeable. The chest and back are common areas to observe tinea versicolor. There can be 100 or more in some infections. This can be treated with topical selenium sulfide or an oral antifungal agent. 86 .What advice should be given to a parent who has a child with Fifth Disease? (A parent may experience joint aches and pains) Fifth disease, erythema infectiosum, is a common viral exanthem seen in children 5 - 15 years of age. This produces a maculopapular rash that blanches easily. This rash is not pruritic but may last for several weeks before it completely goes away. Children are allowed to attend school as long as they have been fever free for 24 hours. Discomforts of this illness (fever, body aches, etc.) may be treated with acetaminophen or ibuprofen. Adults who are exposed to children with Fifth Disease may complain of arthralgias and myalgias for several weeks. 87 .A 6 - year-old has been diagnosed with Lyme disease. Which drug should be used to treat him? (Amoxicillin) Amoxicillin, doxycycline, and cefuroxime have all been shown to have equivalent efficacy for treatment of Lyme disease. However, because this patient is 6 years old, he should not be given doxycycline as a first line treatment unless the other regimens are contraindicated. Macrolides like azithromycin should not be used first line because they are poorly effective at eradicating infection. They may be used in patients who are intolerant of penicillin and cephalosporins and who cannot take doxycycline. First generation cephalosporins like cephalexin are poorly effective and should not be used. 88 .A patient presents with small vesicles on the lateral edges of his fingers and intense itching. On close inspection, there are small vesicles on the palmar surface of the hand. What is this called? (Dyshidrotic dermatitis) This dermatitis is intensely pruritic and involves the palms and soles and lateral aspects of the fingers. Over a couple of weeks, the vesicles desquamate. Recurrences are common. Seborrheic dermatitis affects only hairy areas of the body. The vesicles might raise suspicion of a viral infection, but this is not present in this case.
93 .A patient presents to the minor care area of the emergency department after being bitten by a dog. The patient states that the dog had a tag around his neck and had been seen roaming around the neighborhood for days before the patient was bitten. The dog did not exhibit any odd behavior. How should this be managed? (Report the bite to animal control and administer appropriate medical care) All 50 states require reporting of animal bites to animal control or the state’s appropriate authority for reporting animal bites. It sounds unlikely that the dog could be infected with rabies, but rabies prophylaxis must be considered after all history and information has been gathered. 94 .Patients with atopic dermatitis are likely to exhibit: (itching) Atopic dermatitis is diagnosed on clinical presentation and includes evidence of pruritic skin. It is recurrent and often begins in childhood. For decades the "atopic triad" has been used to refer to patients with atopic dermatitis, asthma, and allergic rhinitis. This has recently been called into question. A similar triad, known as Samter’s triad, consists of asthma, aspirin sensitivity, and nasal polyps. Samter’s triad is not the same as the atopic triad. 95 .Which test is NOT suitable to diagnose shingles if the clinical presentation is questionable? (Complete blood count (CBC)) Herpes viruses are the causative agents in shingles, chickenpox, genital herpes, and oral fever blisters. Diagnosis is usually made on clinical presentation. However, in questionable cases, lab tests may be employed. A Tzanck preparation is a rapid test used to diagnose infections due to herpes viruses. Cells taken from a blister’s fluid are smeared on a slide and stained with a Wright’s stain, or the fluid can be used for other methods of testing. DFA is the most common test employed for shingles diagnosis because it can be rapidly performed and offers results in about 90 minutes. PCR may be performed on skin scrapings, serum or blood for herpetic diagnosis. CBC may indicate a patient with a viral infection, but it is nonspecific for herpetic infections. 96 .A patient exhibits petechiae on both lower legs but has no other complaints. How should the NP proceed? (Order a CBC) The presence of petechiae on the lower legs (or anywhere on the body) should prompt the NP to consider a problem that is related to a low platelet count. A CBC should be checked to assess the platelet count and for any evidence of anemia from blood loss. If the platelet count is found to be low, referral to hematology should be done. Blood cultures are of no value in this patient, who is otherwise asymptomatic. 97 .A 9-year-old has been diagnosed with chickenpox. A drug that should be avoided in him is: (aspirin)
